2000_0805 (2) W ATER
Zssued _1 O Pinished Zmploy Cr/'E Grid map
3 '1� 5 J - ticq�y�
Name: fr01k ul/JO . / v Address: J
?hone Number: (EM): `�72 - `4b.2 " qtf <, (WIC):
Time for Was locate
Check for: Acwsscr tot_ Mesa Lisa lc Cb.ck water prom= _ Initial osier mJocation *mice ltresad
1.8ackflow Inez. 2. 2321ir 3.faintenance 4 .Oth.r
Backflow Insp. A.Main Line A.Pumps A.Line Locate
3.Valvss B.Nater Tower 3.Inapection
0
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.3ydrants D.Equipment D.Excavation
Re-Cert. Date E.Safety
E. Reason for failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
o . List of safety equipment at site if applicable:
A. Barricades 3. Canes C. Tape D. Lights E. Other
Request. for Serviceman:,
7.:.! Meter/Service Leak: Classify - City: V Customer: _!_
A.Wazer Loss (Fximu. :: GPM ?ire plug flushing Total Gallons
:.Was Water Metered: Yes No __
:7 Customer Notified: Verbally, >/
Vehicle /Equipment Used
3.I: Meter Change Out: / Unit # Hiles Ere Equip
A. Old Meter09 / 32 3 Reading too
/
3. New Meter/ < �/ / g 57 > ?
Reading 0
5
:"..Old Meter' Size /Type: (
. � - / /'CG /5l.)4- . .. - --D ..New Necer size/Type (X / ai.15fcf- . ..
:.Type of work performed or findings: C,CCr7 g t o fr
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . 4anhours : , 1,S Crew members:
11.List Materials Used:
12.If you had an accident /incident while performing this request. Did you report it? yes or no
13.Weter Utilities meter inspection: pass or fail .
14.Aow many trips to do task?
Signature,