2000_0812 WATER
Issued / a' 7'inished
/ ` — Grid, map
Name: �/(/ /f 1 5�
! l i f Address: /o �� )1_/_ t
?hone Number: (EN) : (W):
Time for dater Locate
Check for: .stand wm___ Meese Ls.i C iock w. sr magus: Initial must edoaeion isapecdos IreW
1.3ack:Low Inso. 2. almic 3.$aintenance C_
eacictiow tnsp. A.Main Line A.Pumps A.Line Locate
& Valves & Water Tower 8.2nspection
3 cfLaw Cer:.Da:e C.Service Line C.Samples C.Tap
0.3yd.rants D.Squi,pmeat D.bccavation
Re -Cert. Date
5. Reason for failure: A. Electrolysis H. New construction C. Poor installatiar.
D. Other
4. List of safe.:y equipsent at site i_ applicable:
A. 3a.- :icades 3. �aes C. ?ape D. Lights Other
Request for Servicsmant' .e
7..T! Hetsr /Se:7i_s :.fak: Classify - City: Customer: •
;.wa =sr Loss (!p GPM , ?ire plug rushing Total Gallons
3.Was Water Metered: Yes No
:.was Customer Notified: verbally __
Vehicle/Equipment Used
2.3_ Meter Charge Out: Unit # Miles Firs Equip
arid 1 �� F7 7d Reading / 7 Q. ` , 2 \J
7.-014 Hets+ /
3.New Heterf2 - > / , Rsadius_ 1 t
C.OLd Meter Sire !rf �� �
/� : D . New Hater Size/type
3.Type of work performed or findings:
9.I: mainline or deep service repair, describe type of pipe or service line and condition:
LO . Malabo: s : Crew members:
LL.Lis= Materials Used: _
L2.If you had an ac:ident/Lne:dent while performing this rogues . 0 d you report it? Yes cr na
watec ties sets inspection: pass fail 'v
L3. yell! r _ or