0000_0000 WATE R
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Issued / Finished Employee �1C'; j� t' Grid map
Name: I /ski ��s'9i5 — :S 71 AL Address: _5%1s �Af4e) c,, w-I le t..<:. .6
Phone Number: (H4): (WR):
Time for Water locate
Check for: Accuracy test_ Meter Leak Check water pressure: Initial meter relocation inspection Ro
1.Backf low Insp. 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.Bydrants D.Equipment D.Excavation
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor installation
a D. Other
6. List of safety equipment at site if applicable:
A. Barricades B. Cones C. Tape D. Lights E. Other
Request for Serviceman: <f49/13 .frPl/E —.7... ( ./..5.2 1 Q' 2 t7
7.If Meter /Service Leak: Classify - City: Customer ,;
(4..
A.Water Loss (Fuimate): GPM Fire plug flushing Total G ,
B.Was Water Metered: - Yes __ / No
C.Was Customer Notified: Verbally V ."--
DOORKNOCEag
Vehicle /Equipment Used
8.If Meter Change Out: Unit # Miles Erg Equip
A.Old Meter# ? Z D 2 7Reading i(5 7 u J
7 - �` ' 'I 9 7 02 � 0 ,
1
8. New Meter #2 /' 3 /. j 0 Reading 0
s/* /�,, / 1
f 31
C.Old Meter Size /Type: 4 D. New Meter Size 5 / f lYj
E.Type of work performed or f'ndings:
fi 6 A ( hgiAl?fd 4ti /kJ y
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: J Crew members:
11.List Materials Used:
12.If you had an accident /incident while performing this reque t. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14.How many trips to do task? A
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