2001_1107 WATER
issued P'/`D/ Finished `< 6 43 Employee A_� &Y1Y∎ Grid map
name:
■ ., 0. . Address: d#; %3 .944
?hone Number: (HM): (WX):
Time for Water locate
Check for: Accuracy test: X Meter Leak: Check water pressure: Initial meter relocation inspection Re -read_
U Sfe below '
1.Backflow Insp. 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inspection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation
D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. , Tape D. Lights Lights E. ,/ p
Request for Serviceman: /17 ST vc!L
/!' /�� l /F/ Dl
7.If Meter /Service Leak: Classify - City: Customer:
A.Water Loss (Estimate): GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOORLNOCKER
Vehicle /Equipment Used
8.If Meter Change Out: t Unit # Miles Hrs Equip
A.Old Meter# 77 er7tewD Reading.O /J
3 . New Meter# o g”/ Reading L S /J
C.Old Meter Size /Type: ic45e/ D D. New Meter Size /Type 8 e! ( 1
E.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: 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.Water Utilities meter inspection: pass or tail
14.How many trips to do task? I
Signature