CF-Coppell Rd SC-WO020215Issued:
Name:
Finished:
Phone Number (HM):
Time Started:
1. Stoppage.
A. Use Jam Tape
B. Use Jet Truck
C. Rodding Machine_
D. Excavation
SEWER
Employee: 0_~lie
Address:
(WK):
Grid Map:
a.m. p.m. Date: Time Finished: __ a.m. p.m.
2. Renair/Re~lace 3. Maintenance 4. Other
A. Main Line A. Lif~ Station A. Line Locate
B. Lateral Line B. Manhole B. Inspection
C. Clean Out C. Samples C. Tap
D. Smoke Testing
E. T.V.
Parts Used: # of Employees: Equipment Used: Vehicle #:
Request for Serviceman:
Stoppage on: City Customer Install Clean-Out
5. Have you been back at this same location in the past 3 months? YES or 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 correct this situation? "n~"~ ~3 ~_lq ',3 cX_~,x3 ~
YES or NO
9. Estimate Jet Truck Gallons Used:
Is Site Restoration Needed? YES or NO
In the event of an overflow, did you process a TNRCC report: YES or NO
10. Estimate Gallons Overflowed
11. Was Chlorine added to disinfect? YES or NO
12. Was Site 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
Picture/Video? YES or No Notify Other Utilities? YES or 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: