SS9402C-CS 960919 ROA D/ YS .5 %
Employee~ Grid map
Addr~:~
Phone' (hm)..~/~ ,/~-~ g ? / ~ (wk).
1. T~ of ma~E ~ Concern* 2. Na~ of ~blem ' D.F~=~o~ d~ ~ ~ -
B. Asph~t A. Hold~g ~ E. Ro~g ~ ~/5 ~M~fl~
C Grovel B Pot hole F T~R~e ~ ~ ~
D. D~n · C~ M~ hole G. 0~ 15 ~~/*-/
· Strut Rep~ .... , ~ey R~ , Sidew~ Re~ Sq. Ft. ~ 1 2 or 3
3. ~o ~u~ ~e problem or who is re~nsible for ~e pwblem ~ ~ ~/
~e ci~ E. ~o~ u~ ~m~y ~ ~ ~ ~~
B. The customer
C. The contractor
D. The developer
How were the repairs made:
A. Cut out and blocked
B. If concrete - was it doweled and pinned with steel.
C. If asphalt - was site cleaned out
2 inch
D. If asphalt - was site dry
E. If asphalt - was site cleaned from dust or lose particles
F. If asphalt - was TAC added to all joints.
G. If asphalt - was seal coat applied?
H. If site is asphalt or base, was it compacted with a
"Wacker Packer" or lumping Jack?
I. Was a roller used
yes nO
yes no
yes
yes
yes
yes nc
yes no
yes no
yes no
Note why did this problem occur
A. Settling of site
B. Poor construction
C. Shoulder rolling off
Do
Turning radius
Other
Were barricades used yes or no
Were barricades removed yes or no
Barricades for Other Departments
Were the customers informed yes or no
Was door knocker left yes or no
9.
10.
11.
12.
Weather conditions
A. Dry D. Cold
B. Wet E. Oth~
C. Hot
Does the ditch need cleaned out: yes
Does the Culvert need to be cleaned or replaced: yes
Do the brick pavers need to be replaced: yes
Was there an accident/incident: Yes
How many trips to do task?
Or nO
or no
or no
or no
Did you report: yes or no
Signature