2000_0716 WATER . ,
Issued 7/- Finished Employee Grid map
Name: a
�(/�0.AP!/1 Address: 2 M %A L1()(:) `(J 1 10
?hone Number: (HM): (WX):
Time for Water locate
Check for: Accuracy test: Meter Leak: Cbcck water pressure: Initial meter relocation inspection Rs-read
_
1.8ackflow Insp. 2. Repair 3.}4aintenance 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 E. Other •
Request for Serviceman: 712 iS '^T &C4<,
7.If Meter /Service Leak: Classify - City: Customer: //
A. Water Loss (Estimate): GPM Fire plug flushing Total Gallons
3.Waa Water Metered: Yes No
C.Was Customer Notified: Verbally DOORIWOCIQ:R
Vehicle /Equipment Used
8.If Meter Change Out: ) ,, V Unit # Hiles Hrs Equip
A.Old Meters S 7`75 Reading �� c / d- y c 2 2f-2. 2' a
22 (456/6 0 '
•
3.New Hetert Reading
Size /Type: yp :��
e:� '
C.Old Meter i / D. New Meter Size /Type L 4 2-
^a.Type of work performed or findings:
9.If mainline or deep service repair, describe type of pipe or service line and condition: .
4-_- 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 fail •
14.How many trips to do task? `
Signature tl—� )1t