Peninsulas-CS 970930WATER
Grid map
P~one Number: (H~): (WK):
Check for: A~cu~c7 ~: M¢~r ~ C~k water prague: ]a~';-~ m~r ~o~,ioo ia~:~ P~-m~d__
1.Backflow InsD.
Backflow Inep.
Bkflow Cer~..Da=e
Re-Ce~. Date
5. Reason for failure:
2. Repair
A.Main Line
B.Valvee
C.Service Line
D.Hydrants
A. Electrolysis
3.Maintenance
A.Pumps
B.Wa=ar Tower
C.$amples
D.Equipmen=
E.Safety
New cons=.--action
Lis= of safe:y equipment at site if applicable:
4.Other
A.Line Locate
B.Inspec~ion
C.Tap
D.Excavation
C. Poor ins=alia=ion
D. Other
A. Barricades 5. Cones~C. Ts_pa DH Lig.h=s E. OCher
7.If Me=er/Se.--zice Leak:
A.Wa=er Loss ~:~i=mm~: G~M
Y.Was Wa=er Me=ered: Yes
l. Was Customer Notified: Verbally__
Classify - City:
Fire plug flushing __
No
~.If Mane= Change Ou::
A.Old Mener~ Readinq
B.New Me=er~ Readin~
Total Gallons
Vehicle/Equipment Used
Unit # Miles Hfs Equip
C.old Me=er Size/Ty!~e:
E.Type of work performed or findings: --
D. New Me=er Size/Type
9.If mainline or Seep service repair, describe type of pipe or service line and condition:
10.Ma=hours: Crsw m~m~ers:
11.List Materials Used:
12.If you had an accident/incident while performing this rmquas=. Did you rSpog"~ l=? yes or no
or fail
Signature
~4.How many =ripe to do Cask?