WORKS SERVICES REQUEST FORM - Shire of \\DBK-FS1\data\Engineering\Engineering Administration\Forms\Form WS030 Works Services Request Form.doc WORKS SERVICES REQUEST FORM Date:

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  • \\DBK-FS1\data\Engineering\Engineering Administration\Forms\Form WS030 Works & Services Request Form.doc

    WORKS & SERVICES REQUEST FORM

    Date: Time: Taken By:

    WR #: Assessment #:

    CUSTOMER DETAILS:

    Name:

    Address:

    Locality: P/C:

    Phone (Home): (Work):

    Mobile:

    Email:

    Please tick box of preferred option of contact

    NATURE OF REQUEST:

    TREES / BRANCH ROAD MAINTENANCE PARKS & GARDENS

    Fallen On Road (please complete information below *)

    Grading Mowing

    Pot Holes Toilets

    Fallen Other (please complete information below *) Drains, Culverts Playground Equipment

    Dangerous Verges Reticulation

    Blocking view Bridges Bins

    Other Other Other

    If other, please describe:

    LOCATION & NATURE OF WORKS:

    Road, Park, Reserve, Building Name:

    No: Street:

    Suburb:

    Nature of Request:

    * Fallen Tree/ Branch Details:

    Exact or closest Location / Intersection / Rural Road # / near Bridge / House / Farm:

    Approx size (diameter of trunk / branch):

    Does it cover whole or part road? Yes / No (please circle)

    Can traffic drive around? Yes / No (please circle)

  • \\DBK-FS1\data\Engineering\Engineering Administration\Forms\Form WS030 Works & Services Request Form.doc

    OFFICE USE ONLY

    Priority:

    High (within 1 day) Medium (within 1 week) Low (within 4 weeks)

    Request Allocated to:

    Action:

    Forwarded to:

    Action:

    Completed by (Signature):

    Completed date:

    Please return completed form to Works Supervisor or Engineering Admin Officer

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