0000_0000 WATER
Issued _ Fi Employee Grid map
�
G � � 0 4
Name: 4:.14122 Address:
Phone Number: (RH): (WK):
Time for Water locate
Check for: Accuracy test: Meter Leak: Check water prtssutt: Initial meter relocation inspection Re -read
1.Backflow Inst. 2. Repair, 3.Haintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inepection
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.Equipment D.Excavation
Re-Cert. Date E.Safety
Reason for failure: A. Electrolysis B. New construction C. Poor installation
5. D. Other
6. List of safety equipment at site if applicable:
A. Barricades 3. Cones, / Tape D. Light % E. Other
Request for Serviceman•_ _/-__L
7._f Meter /Service Leak: Classify - City: Customer: —
A.Water Loss (Estimate:: GPM Fire plug flushing Total Gallons
S.Was Water Metered: Yes No
,,.Was Customer Notified: Verbally 4-------- DOORICHOCICER
Vehicle /Equipment Used
o.If Meter Change Out: Unit # Miles Hrs Equip
1 �ci .,a2C(
A.Old Meter ? '71-- / 52 Reading J2 ;6S 1
I
3. New Meter #.0 ���(3 Reading r_5
/�
: �
^.Old Meter Size /Type D. New Meter Size /Type di
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: _,,,I
r
11.List Materials Used: G.---}
, aJ C - ) - 12.If you had an accident /incident while performing this r [iest. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14 . How many trips to do task?
Signature