0000_0000 W ATER
Issued :____„_ Tinished Employee A . Grid map
r
Name: Address: Q • 0 / / 7. 41
?hone Number: (ffi4) : /
Time for ware: locate
Check for: Accuracy us:_ Maur Laic Mack water pressure: Initial mew rslooasiea impectioa jaisad
1.Backflow Irtso. 2. Jeoairr 3.4aintenance t.Qthsr
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves &Water Tower B.Inspection
Bk_low Cert.Date C.Service Line C. Samples C. Tap
D.Eydrants 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. Canes C. Tape D. Lights E. Other
Request for Serviceman:
, 1/4A:1 C 0 u fr
7.:f deter /Se_rvice :Teak: Classify - City: Customer:
A. pater Loss (E:4004: ?ire plug flushing Total Gallons
S.was water Metered: Yes No
:.was Customer Notified: Verbally DOORZNOCKEK
Vehicle/Equipment Qsed t
3.I: Meter Change Out: G Unit # Miles Ere Equip
A. Old Met # / (pc)4 Reading Z
2 I
3. New Meter# 1 b r/ 7 l `, 7 Reading 0
C.old Meter' Sire /Type: S* /L '4 41 . --D: --11ew Meter Size /Type 4 �e 01/9,5 *'2 ..
=.Type of work performed or findings:
R • 1
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10 . lianhours : / Crew cambers: _/
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 inapectioni -pass or fail U•. •
14.How many trips to do task?
Signature,