1218 WATER
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Issued Finished/ 2 ! r Employee / <// t Grid map
Name: Address: 5/3 (;:"X`
Phone Number: (8M): (WX)
Time for Water locate
Check for: Meuncy wt:_ Maw Luk Check vaor pressure: kids! mast edoeuion iaapectioe �� • jta.t d
l.Backflow Ingo. 2. Reoair 3.Maintenance 4.Cther
Back_low Insp. A.Main Line A.Pumpe A -Line Locate
B.Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Bydrants D.Equipment D.Excavation
Re-Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
o. List of safety equipment at site it applicable:
A. Barricades 3. Cones C. Tape D. Lights E. Other
Request for Serviceman:
Meter /Service Leak: Classify - City: Customer:
;. Water Loss (Fsimstst: G ?M ?ire plug flushing Total Gallons
3.Was water Metered: Yes No
_.Was Customer Notified: verbally DOOREMMICIOME
Vehicle/Equipment Used
3.5: Meter Change Out:: Unit Miles Erg Equip
A.Old Meters QQ
$Jf r/ G % Reading � ✓ / /mil �/ Y Z f /
3 . New Meter# 1 G � y' Reading t
C.01d Meter Size /Type: / / " �6 1: •. - -D: - Meter Size /Type "
(.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . 4anhours : 3, ,/, , Crew members: ,
11.List Materials Used:
12.11 you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: page or fail
14.Aow many tripe to do task? •
Signature