0000_1204 / / / �f WATER k .. ' Issued 2 "'7 Finished ` / Employes - Grid map
Name: ( e_) n L a--U Lt, Address: q C ( o LJ
J s ,
?hone Number: Mu: (WK) :
rime for water locate
Check f or : Accunc7 teat:_ Man Leak Cbat water pressure: Initial meter relocuion inspection Re -read
1.Backflow Inso. 2. Repair 3.14aintenance t.Other
Backflow Insp. A.Main Line A.Pumpe 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: C/ b2 , 1-e/Z, - --- ?-, 4/7 9 9 5 -e-cer_e_i
Meter /Service Leak: Classify - City: Customer:
:,.water Loss (Agnate:: GPM Fire plug flushing Total Gallons
3.Was water Metered: Yes No
:.Was Customer Noti Verbally DOOREZIOCK R
Vehicle /Equipment Used
3. If Meter Change Out: U /# Miles Firs Equip
A.Old Meter# / Z yi yy5 - 5J /i2' < Reading / -V " 0777,V
3. New Meter# 1,031 J( Readingv eL
Meter Size/Type: 9 ^' iii, e D : New Meter Size /Type / 7›.?..)-_.w.7
...Old
(.Type of work performed or findings: 5&/,f/ /�c 1
. /l_/ `/J
9.If mainline or deep service repair, describe type of pipe or service line and condition:
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