0000_0000 WATER
Issued J Finished
l Employee _ ) fL ... Grid map
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Name: 61,—,/d91n /
9 — ttJ /,v,vk— Address: L'I 1 3 d 7I 3 CJ c,c, 65 f
Phone Number: (HM): (WK):
Time for Water locate
Check for: Accuracy teat:__ Meter Leak: Check water pressure: Initial taster relocation inspection Ito
1.Backflow Insp. 2. Repair 3.Maintenance 4.0ther
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves S.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 equiattnt at site if applicable:
A. Barricades B. Cones CC. Tape D. Lights E. Other
Request for Serviceman: C_i//,/U f/L l i /� f._/0 7 0 f ? 2 7,5-
7.If Meter /Service Leak: Classify - City: Customer: •
T-
A.Water Loss (Esciante): GPM Fire plug flushing Total Gallons
B.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOOM
Vehicle /Equipment Used
8.If Meter Change Out: Unit # Miles Hrs Equip
A. Old Meter# ,r7 92..2 f Reading o y46 30
B.New Meter# n 9 cz Y/3 9$ Readin 1
C.Old Meter Size /Type: f4'4 c/ cr.fr Ti.' > D. New Meter Size /Type S /_, (a_/_, ,.. - .7?,- fr•a
E.Type of work performed or findings: „ 4 /( T,r
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhoura: 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.H cn Utilities meter inspection: pass or tail 2
14.How many trips to do task ? ��
Signature/ .