2001_1204 WATER
Issued iv : C Finished Employe � / - Grid map
Name: Address: /
SS
5
•
?hone Number: (8M): (WIC) :
Time for Water locate
Check for: Accuracy test :_ Mast Lack Check water pressure: Initial meter relocation inspection Rs - read
1.Backflow Inez. 2. Retied: 3.Maintenance l.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspsction
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Eydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
5. Reason fcr failure: A. Electrolysis B. New construction C. Poor installation.
D. Other
o. List of safety equipment at site if applicable:
A. Barricades 3. Cones C. Tape �1 D. Lights E. Other
Request for Servicema- L.- -144 `� /
n e 4 : / /0 � � 25
7.1! Meter /Service Leak: Classify - City: Customer:
A. Water Loss (Eninute:: GPM ?ire plug flushing Total Gallons
3.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOORl1QiOC]lER
Vehicle /Equipment Used
3.I: Meter Change Out: Unit # Miles Ere Equip
A.Oid Meters G / Z/7 7'* / ) Reading/ ///" ` /Z y
3. New Meter # Z # 1 � 2 Reading
C.Old Meter Size /Type: --40:-New Meter Size /Type �� /'
E. Type of work performed or findings: 9 % /
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhoura: ,3�/ Crew members: _f
II.List Materials Used: ,
12. If you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many trips to do task?
Signature,