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WATER / -
hl a : f Gridm
NI= Adidresc A O
Pltars `srr.ee- (FCC ter
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Chee;c for .a.-:erxv = Meter Leak Cluck rarer press=
tnidai =era :iiaca ert is pee s Re-read
1. pact /cm imp, 2 E 3. ; daiag•• - 4 . Qllit
Baceaer Lisp. A. Main Line k. Pump A: Liss Loam
B:c'.ow Ctn.. Due B. Yaives B. Wacer Tower B. Line Locate
R =-C= = Date C. Service Line C. Samples G Tip
D. Hydrants D. Equirocat D Excavadoe
E. Safety
S. Rama hoc bare A. E?mcuolysis & New Ca ussucios C Poor lasoluios D. Mee
6. List of safety egaipoe s at ass if appiieabic
A. Bar ieades H. Cones C. Tape D. Lights E. Odic
Request far Sc ecv:s ,41 IL r/1!C its ' 'e lm
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7.
If MeteriServi= L:;lc amity: - City: Customer
A. Water Lau (z alte): GPM Fire plug flushiag Taal Gallons
a Was Wuerltusx± Yes No
C. Wu Cas ese Notified: Verbally Dogdmodcs -
I/chi,ciaEgnipment Geed
3. (' : : :e a l:s: Cdr # 1Cles H s 'egt:ipmeac
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3. N ell Mrs = !s 4 :// S %3 Etxdiag
C. Old Mr--r p e << D Meter S z Type r at /5
"c. Type awed performed or Tuxtla's: / e..S 7 i'-, e 7e4
9. (` =s _:_e :r :e: ;e-�:: wait, describe type of pipe or service line :cd caedidaa:
,7 ......._. iS� C ::•.v G P
I Vie: fo ting this : 'les :. '' ?:C !:':. :c :c? Y :s „ :c
V#4 3. WI : :: Utl;r'es sxr. -reetiert: or fait
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