Beltline East-WO 970930Phone Number: (~):
Time for Water locate --
1.Backflow InsD.
Backflow Insp.
Bkflow Cea. Date__
2. Repair
A.Main Line
B.Valves
C.Service Line
D.Hydran=s
Re-Ce.---. Dare
5. Reason f~r failure:
A. Electrolysis
3.Maintenance
B.Wa=er Tower
C.Samplee
D.Equipmen=
E.Safe=y
New const:n~c=ion
List of safe:'/ eguipmen= a: sire if applicable:
A. Barricades 2. Cones C. Tape D.
Reouest for Serviceman: .~-~ --
A.Line Locate
B.Inepec=ion
C.Tap
D.Excava=ion
C. Poor inn=alia=ion
D. Other
Lights E. Other
7.1f Meter/Sea, ice Leak: Classify - City: __
A.Water Loss ~m~: GPM Fire plug flushing __
B.Was Wa:er Metered: Yes No
Z.Was Customer Notified: Verbally __DOO~.KNO~ --
S.If Me=er Change Out:
A.Old Mener~ Reading
B.New Meter~ Readinq
Gallons
Vehicle/Equipmen= Used
Unit 9 Miles Hfs Equip
C.Old Me=er $i:e/~e:,
E.T.~.e of work perfo~-med or findings:
D. New Me=er Size/Type
9.If mainline or deep service repair, describe type of pipe or service lane and condition:
10.Manhours: Crew members:
ll.Lis= Materials Use~:
12.If you had an ac=iden=/lnciden= whale performing =his request. Did you re~or~ it? yes or no