SW0101-CS0104280d/28×01 11:52 CITY ~lc COPPELL a CITY OF COPPELL
Mrs. Barnett
113 Simmons
04×28/01 11: 52 C I TY OF COPPELL --> CITY OF COPPELL NO. ?58 Q02
.-. T~e S{ased: ~ a,m. ~ p.m, Dai?: T/m~ finished ~i,m. p.m.
~ 2 Reuair~lace 3 ~a~t~i~ 4. Ot~r
A. Use j~ ~pe A. Ma~ Lme A, L~t sta~on A. L~e Loca~e
B, Usc jet ~ck B. Lateral Lag B. Ma~ole B. ~specfiou
C, Usc roddag C Clean Out C. Samples C. Tmp
Mac~ D. Smoke tests
D. Excava,oa E T.V.
Pa,s Used: g of Employees: Equip. Used: Ve~cl~ a:
Stoppage on: City Customer or No
5. Have you becn back at this same location m the past 3 months7 Yes __ No ~
6. Type of problem:
A. Se~arafiou C. Hair roots E. Other
B, Bad ~ap D. Bellies or rambow
?. What needs to be done to correct this situation:
8. In the event of an overflow, did you process a TNRCC report: yes or no
9, Estimate Jet Truck Gallous Used: 10. Estimate g~llous overflowed
1 I. Was cktorme added to disinfect yes or no ,
Is Site RescoraUou Needed? Yes __ No ~ 12, Was sight cJeaued 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
Picture~Videoed'? Yes ~ No ~ Notify other utilities yes no __
Work location: Alley Street Intersection ,Field
Customer con:ac~: In person Doorknocker
14. [lyon had au accident/incident while performmg this request. Did you reporl it Yes or No
Signature: