0000_1118 (
WATER -
Issued ///U Finished 0
A Employee �� Grid map
Name: s � � G�f J
Address: C ' OU e S i i'ecR
Phone Number: (HH): ():
Time for Water locate
Check for: Accuracy teak_ Meter Leak: Check water
pressure: Initial raster reJoeation'eup°cti°4.__ Re-read
1.Backflow Ins). 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line
B.valves A.Pumps A.Line Locate
Bkflow Cert.Date C.Service Line B. Tower C.Inspection
C.Samplea C.Ta
D.Hydrants D.Equipment p
•
Re -Cert. Date E.Safety D.Excavation
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation
6. List of safety equipment at site if applicable: D. Other
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Serviceman•/ -.-e. , /. l AP ! I � .
•
A ii-e...., � , - 4 �.►..' "s - —..-.,—..• ! e i - / - if
7.If Meter /Service Leak: Class' - City: Customer:
T
A.Water Loss Maims*: GPM _____ Fire plug flushing Total Gallons _
B.Was Water Metered: - Yes -- No _
C.Was Customer Notified: verbally 4"---D00B1010CEaR
Vehicle /Equipment Used
8. if Meter Change Out:
1°13/ Unit # Miles Era Equip
A.Old Meter# s * 1 Reading r ?762 2 70
� Meter# � "- "� _ - Reading j
1( e 4.14---
,.?
C.old Meter Size /Type: AW D. New Meter Size /Type -4- Ai /L Y)
E.Type of work performed or findings:
/V - / _ ` )9' 7, _
V ----If - i o -' - .A/ _ , 4 .4'U • IS
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: %( Crew members:
11.List Materials Used: a ,x9 U 4--+- t e__, c, :c,' C r k)0)
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?
A
Signature