2001_1110 WATER
Issued 1 I I Finished
I Employee )R0 Grid map
Name: 2-41//5/t , 1491 ./41 4 . Address: / . 3 Mil /4 / /A,t(J
Phone Number: (HH): (WK):
Time for Water locate
Check for: Accuracy test:_ Meter Leak: Check water pressure: Initial mater relocation inspection Re
1.Backflow Insp. 2. Repair 3.Maintenance 4.4ther
Backflow Inap. 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
6. List of safety equipment at site if applicable: D. Other
�'i Pm
A. Barricades B. Cones �++' Tape D. Lights E. Other
Request for Serviceman: L,/l g /rt 141jf'Ajf,jl 44 9.3 7 3k Vi' 3'
7.If Meter /Service Leak: Classify - City: v Custer; •
T-._
A.Water Loss (Estimate): GPM Fire plug flushing Total Gallons
B.Was Water Metered: Yes N
C.Was Customer Notified: Verbally _____ DOORXNOCalt __
Vehicle /Equipment Used
8.If Meter Change Out: Unit # Miles Firs Equip
A.Old Meter# y,5 7, 3 �i �/` 'Reading / 1 O ; �
3 4 L� 9 7C) � � �j
8 . New Meter# 2 / y3 L/ I 7 Reading 0
k i
C.Old Meter Size /Type: 61 ` ' '.- D. New Meter Size /Type
E.Type of work performed or findings:
1 1. 772-- .C._ 7 47- 1 -`; 0 �
.G
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: Crew members: ii
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? . `;
Signatut.