2001_1128 Fax fb Wethef 6/11
WATER /
Luued: / /—aT&)/ Finisbed: 1� , 3 maple • Grid map: __-- -_
Name: t nC � Address:
Phone Number. (KM) ) (WK)
Check for. Auuracy test Meter Leak: Check water pressure:
Initial meter r :loation:aspe :t:oas Re -read
1. Hackflow [asp, 2. Repair 3. Maintenance 4. Out
Backflow trip. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Dace B. Valves B. Water Tow:: B. Line Locate
Re -Cert. Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equ:�pmenc D Excavation
E. Safety
S. 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 C. Tape D. lights E. Other
Request for Services: rn �� J,O� t (C,
7. If Mete "Sc :ice Leak: C:as;_, City: Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Was Water Metered: Yes No
C. Was Customer Notified: Verbally Doorltnockcr-
Vehicle/Equipment Used
8. If M: ::: C,:a-g: Out Unit : `Gies Hrs Equipment
•
A. Old Meter 4 ,) J$. :.36 Reading �.
B. New Meter 4 a /a Ste Reading f
C. Old Meter Size/Type: S/ Sl /11 aet t D New Meter Size/Type
E. Type of work pcformed or findings:
9. If mainline or dpp service repair, des be type of pipe or service line and condition
10. Man- hours: Crew Members.
1 1. List Materials Used:
12. If you ha: 1 :: icride:ttr ?:c ::: :c while performing this request. Did you repor. :t' Yes or no
•
13. Water calico ,:,e:er icspc - :cc : pass or fail
14. How many trips to do ask?
Signature ,