0000_0000 WATER
Issued Finished Employee �t�fz_. Grid map __-
Name: . P.: Address: 7 3 3/)64nI ikYA I- O�sS
Phone Number: (HM): (
Time for Water locate
Check for: Accuracy teat:___ Meter Leak:__ Cbecr water pressure: Initial meta relocation inspection_ Its
1.Backflow Inso. 2. Repair 3.Maintenance 4.Other
Backflow Insp. 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
D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones .A
C. Tape D. Lights E. Other
Request for Serviceman: f /5 G; I � i- - 7 , 41-R/7 (p 5,k 7,
7.If Meter /Service Leak: Classify - City: Customer; •
T
A.Water Loss (Estianau): GPM Fire plug flushing Total Gallons
B.Was Water Metered: - Yes N
C.Was Customer Notified: Verbally DOOM
• Vehicle /Equipment Used
8.If Meter Change Out: / Unit # Miles Firs Equip
A.Old Meter #� /ICY' 16 Reading � ) ( - /CD ,_.5 c c(
B.New Meter# ( 7 J Y3 Reading
C.Old Meter Size /Type: D. New Meter Size �"/ / "/
/TYP e
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: \ 2 ,-- 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?
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