CF-Fire Station 2-CS 970923Grid map
Name:. Address:
Phone: (hm). (wk)
1. T~ of ~ A. Con,m* 2. Na~ of ~blem
B. A~h~t A. Hold~g ~
C. G~v~ B. Pot hole
D. Din C. Mud hole
*S~t Rep~ , ~ey Rep~ , Side~
D.Previous site has settled
E. Rolling street
F. Tree Roots
G. Other
~Sq. Ft. Priority I 2 or
3
Who caused the problem or who is responsible for the problem
A. The city E. Another utility company
B. The customer F. State of Texas
C. The contractor G. Other.
D. The developer
How were the repairs made:
A. Cut out and blocked yes
B. If concrete - was it doweled and pinned with steel, yes
C. If asphalt - was site cleaned out
2 inch yes
D. If asphalt - was site d~ yes
E. If asphalt - was site cleaned from dust or lose particles yes
F. If asphalt - was TAC added to all joints, yes
G. If asphalt - was seal coat applied? yes
H. If site is asphalt or base, was it compacted with a yes
"Wacker Packer" or lumping lack?
I. Was a roller used yes
no
no
no
no
no
no
no
no
no
Note why did this problem occur A. Settling of site
B. Poor construction
C. Shoulder rolling off
D. Turning radius
E. 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
7. Weather conditions
A. Dry D. Cold
B. Wet E. Other.
C. Hot
8. Does the ditch ne~xi cleaned out: yes
9. Does the culvert need to be cleaned or replaced: yes
10. Do the brick pavers need to be replace: yes
11. Was there an accident/incident: yes
12. How many trips to do task?
or no
or no
or no
or no
Did you report: yes
Signature
or no