Lakeside V2-WO 960722Issued
Name:
phone Number: (HM):
Time for Water locate
Check for:
1.Backflow Insp.,,
Backflow Insp.
Bkflow cert.Date
Re-Cert. Date
5. Reason for failure:
(WK):
2. Repair
A.Main Line
B.Valves
C.Service Line
D.Hydrants
A. Electrolysis
-- ~ Grid m.ap
Initial meter relo~atlon inspection R~r~ad__
A.Pumps
B.Water Tower
c. Samplee
D.Equipment
E.Safety
B. New construction
6. List of safety equipment at site if applicable:
4.Other
A.Line Locate
B.Inepection
C.Tap
D.Excavation
c. Poor installation
D. other
Other
7.If Meter/Service Leak: classify - City:
A.Water Loss ~-~): GPM Fire plug flushing
B.Was Water Metered: Yes No
C.Was Customer Notified: Verbally DOOR.~IOC.~..,R __
8.If Meter Change Ou::
A.Old Meter~ Reading
B.New Meter~ Reading
Unit
Total Gallons
Vehicle/Equipment Used
Miles Hfs Equip
c.old Meter Size/Type: D. New M~r Size/Type
9.If mainline or deep service repair, describe type of pipe or service line and condition:
Il.List Materials Used~
12.If you had an accident/incident while performing this request. Did you report it? yee or no
13.Wa~.r Utiliti-. met.r in.pectton, P-.. or fail
14.How many trips =o do =ask? Signature