2001_1008 WATER
Issued Finished lot 0 Employee 6)11.9)C l
Grid map
Name: 40.5+1 n £Le M rriat'ki Address: /42/ ,9966&
?hone Number: (HM): (WK):
Time for Water locate
Check for: Accuracy test: Meter Leak:_ Check water pressure:_ Initial meter relocation inspection Re - read
1.Backflow Inso. 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 3. Cones C. Tape D. Lights E. Other
Request for Serviceman: ft7/5 L . 11 & ,N
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
--- / D OORMNOCXER
��ff�� 77 Vehicle /Equipment Used
8.I Meter Cha` fg�OtTtD47 I Le m LZt:1S 1Tnit # Miles Hrs Equip
A.Old Meter'' ` I C " 7L teigi 5. 1 9 6
q wo
3. New Meters 1 (Q' 7 Read /g
I fLrSy '' 6� , ,D Size/Type/ C.Old Meter Size/Type: M Od D. New Meter Size /Type Gr e ,/
E. Type of work performed or findings: Re1 14 L' ri Je.r \ '`.' • es rtcg
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . Manhour s : • 0 Crew member9 : - r ,e t.►
11.List Materials Used: 1 4
' ALL" r ec O 3 - ct - 3 /9 °
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 tripe to do task?
Signature -- •