Attachment_12_-_VBM_Form_3_fillable.docx

VBM Form-3

Instructions: Print, type or use the drop down menus (where applicable) to answer the questions.

Preventive Maintenance and Repair Acceptance Receipt Circuit Number:

USMS District Number:

USMS Site Code Number:

City:

State:

Address:

Street:

Zip Code:

Barrier Manufacturer:

Barrier Type:

Model Serial Number:

Preventive Maintenance Acceptance Receipt |_| Accept

|_| Do Not Accept

State reasons for non-acceptance:

I certify to the best of my knowledge, the Contractor arrived on time and performed maintenance on the barrier or gate in accordance with the Contract requirements.

Print Name:

Signature:

Barrier Gate Repair Acceptance Receipt |_| Accept

|_| Do Not Accept

State reasons for non-acceptance:

I certify to the best of my knowledge, the Contractor arrived on time and performed maintenance on the barrier or gate in accordance with the Contract requirements.

Print Name:

Signature: