Attachment 11_4_TEMPLATE LIST.pdf

ATTACHMENT 11.4

USFS TEMPLATE LIST

Identify the appropriate task for the included list:

Task 1 – Pumping Services ☐

Task 2 – Portable Services ☐

Task 3 – Performing Basic Inspections ☐

Task 4 – Cleaning Services ☐

USFS REQUESTING UNIT

USFS Office requesting unit (Forest/District):______________________________________________

USFS Representative Name:____________________________________________________________

Phone:_____________________________________________________________________________

Email:______________________________________________________________________________

CONTRACTOR

Company Name:______________________________________________________________________

Address:_____________________________________________________________________________

Phone:_______________________________________________________________________________

Email:________________________________________________________________________________

Notes for table below:

*Contractor ‐ Section for Contractor to fill out after completion of work.

** Service date is the actual date work is completed and is for contractor to complete.

Modify table as needed to include additional sites.

Date for expected services:__________________________

TASK ORDER #:___________________________

Date Task order issued:_____________________

X RANGER DISTRICT

Column A Column B Column C Column D Column E Column F

LOCATION FACILITY ID Estimated Capacity (GALLONS) Small (<500 gallons)

Medium (501‐1,000 gallons) Large (1,001 – 2,500 gallons) Extra Large (2,500 – 4,000 gallons) Lagoon (per 1,000 gallons)

SINGLE OR

DOUBLE UNIT

*CONTRACTOR

ACTUAL

GALLONS

PUMPED

** SERVICE

DATE

Example:

Smokey’s Recreation

Area

Toilet # 1 near site 25

1000 Single 500 12/21/2021

Toilet # 2 host site

500 Single holding tank

500 12/21/2021

Toilet # 3 near group site

2000 Double 1000 12/21/2021