ST9505-CS 970930 WATER
~. Grid
I,,u,d ff~_~ ?~ni,h,d ~mploy,,~ map
l.Rackflow Inso.
Backflow Insp.
Bkflow Cer=.Da=e
Re-Ce.-~a. Da=e
2. Repair
A.Main Line
B.Valves
C.Service Line
D.Hydran=s
3.Maintenance
A.Pumpa
B.Water Tower
C.Samples
D.Equipment
E.Safsty
Reason ~or failure: A. Elec=rolysis B. New cons=rue=ion
Lis= of safe=y equipment a= site if applicable:
&.Other
A.LineLocata
B.Inspec~ion
C.Tap
D.Excava~ion
C. Poor installs=ion
D. ember
A. Barricades B. Cones C. Tape D. Lights E. Other
;.If Me:er/Sea;ice Leak: Classify - City:
A.Wa=er Loss ~,~m: GPM Fire plug flushing __
S.Was Wa=er Me=ered: Yes No
:.Was Cus=omer No:ifled: Verbally DOOILENOC~I~t
a.,f Me=er Change mu=:
A.Old Me=erS Reading
B.New Me=erS Reading
To=al Gallons
Vehicle/Equipmen: Used
Unit # Miles Frs
Equip
=.Old Me=ar
E.Typ. e of work Imrfoemed or findinqs:
D. New Me=mr Size/Type
9.If mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: Crew members:
il.Lis= Materials Used:
12.If you had an accident/£nciden= while performing this request. Did you rspo~c £t? yes or no