1217 WATER '•
Issued — _ Finished / A 7 Employee /fr/X6 /X6 Grid map _ ___
Name: , Address: 7�O V 5�
Phone Number: (BM) : (WX) .
Time for Water locate
Check for: Accuracy saw_ Maar Leak Cutat Hater premium Initial maw tolocaion invactio _ R.lsad_
l.Backflow Intro. 2. BB2AiL 3.Haintenance t.Other
Backflow Insp. A.Main Line A.Pumps A.Lint Locate
B.Valvea B.Water Tower B.Inapection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Bydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
Reason fo: f ailure: A. Electrolysis B. Nev construction C. Poor installation
5. D. Other
6. List of safety equipment at site it applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
7.T! Mete. /Service Leak: Classify - City: • Customer:
;.dater Loss (Fstiwatai: GPM Fire plug flushing Total Gallons
S.Was water Metered: Yes No
_.Was Customer Notified: Verbally
Vehicle /Equipment Used
3.If Meter Change Out: Unit # Miles Mrs Equip
7%.01c1 C
.7%.01c1 Meter # /Y a/3 Readin �V 7 (' � g7,7,„,/,
�/ '
3. New Het er # Z / ` 5 / ` l 5 Readin
d Meter Si:e _ e: / '' / 74% 4/ 1 -- - -D: sw Meter Size /Type •N S' / /7/ j �
C. Old /''Yp ��
(.Type of work performed or findings: 'X/ ' ,/ - ��-
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.4anhours: 0/ Crew members: //
,II.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yea or no
13.Water Utilities meter inspection: pass or fail
L4.How many trips to do task?
Signature