2000_0913 SEWER
Issued�inished Employe,. ' Grid map
Name: 1L - L P. 111 . i Address: ' T ' - E - ld is .
1 , n r ' a
Phone Number (I 1) (WK) Cq .� 3. J ��'' I V
Time Started: a.m. p.m. Date: Time finished a.m. p.m.
1. Stoppage 2 Repair/Replace 3 Maintenance 4. Other
A. Use jam tape A. Main Line A. Lift station A. Line Locate
B. Use jet truck B. Lateral Line B. Manhole B. Inspection
C. Use rodding C. Clean Out C. Samples C. Tap
Machine D. Smoke testing
D. Excavation E T.V.
Parts Used: # of Employees: Equip. Used: Vehicle #:
Request for , S (.V J m an. .TI���1'U' , �W � AILIL ' • / �.� • . .�
I
Stoppage on: City Customer Install clean out- Yes or No
5. Have you been back at this same location in the past 3 months? Yes No
6. Type of problem:
A. Separation C. Hair roots E. Other
B. Bad tap D. Bellies or rainbow
7. What needs to be done to c ect t1}i situation:
Ali-C 4AN exmiAklnti
8. In the event of an overflow, did you process a TNRCC report: yes or no
9. Estimate Jet Truck Gallons Used: 10. Estimate gallons overflowed
11. Was chlorine added to disinfect yes or no
Is Site Restoration Needed? Yes _ No 12. Was sight cleaned Yes or no
13. Did you make your supervisor aware? Yes or No
List Safety Equipment Installed at site if applicable:
Barricades Tape Lights Other
PictureNideoed? Yes No Notify other utilities yes no
Work location: Alley Street Intersection Field
Customer contact: In person Doorknocker
Comments on repairs:
14. If you had an accident/incident while performing this request. Did you report it Yes or No
Signature: 3,_1_, /1/4 ,