Attch-4 Utility Locate Request Form.pdf

UTILITY LOCATE REQUEST FORM

DPW FORT LEAVENWORTH

440 MCPHERSON AVE, LOWER LEVEL, DOOR #3

FORT LEAVENWORTH, KS 66027

(p) 913-684-5555 (f) 913-684-2033 usarmy.leavenworth.imcom-central.mbx.dpw-utilities@army.mil

CUSTOMER IS RESPONSIBLE FOR CALLING KANSAS ONE FOR PRIMARY UTILITY CHECKS

1-800-344-7233 http://www.kansasonecall.com/ KANSAS ONE TICKET #:

**MUST BE SUBMITTED SEVEN BUSINESS DAYS IN ADVANCE

**A REMARK REQUIRES SEVEN BUSINESS DAYS ADVANCE NOTICE

*DATE:

*POC NAME: *PHONE:

*COMPANY NAME:

*OFFICE EMAIL ADDRESS: OFFICE FAX:

*EXPLOSIVES? YES_ _NO _

*TRENCHLESS EXCAVATION? YES_ _NO

*DURATION?

*TYPE OF WORK:

*WORK BEING DONE FOR:

CITY/STATE: FORT LEAVENWORTH, KANSAS

COUNTY: LEAVENWORTH

*ADDRESS:

*NEAREST INTERSECTING STREET:

*DRIVING DIRECTIONS/LOCATION OF WORK/MARKING INSTRUCTIONS:

*REMARK (repeat of markings done in the last 15 days):

* SPECIFIC DATE NEEDED:

YES_ NO

(CANNOT BE EARLIER THAN 7 BUSINESS DAYS FROM THE DATE REQUESTED.)

***ONCE PROJECT IS COMPLETE, PLEASE REMOVE ALL UTILITY FLAGS FROM AREA

FOR DPW USE ONLY DATE RECEIVED:

Fax: Email:

GAS: PHONE/COAX/FIBER:

ELECTRIC: ENVIRONMENTAL:

mailto:usarmy.leavenworth.imcom-central.mbx.dpw-utilities@army.mil http://www.kansasonecall.com/

NEC TICKET #: GEOTHERMAL:

AM WATER: LJEC:

NOTIFIED POC OF COMPLETION

ON: Spoke with:

Left message: