W911SA-17-Q-0041_Attachment_3_Custodial_Service_Ticket_Template_(SEP_16).docx

On Site Service Ticket – Custodial Contract number: _____________________ Location: _____________________

DATE: __________

Custodial Service TYPE (include all) ☐Dust Mop ☐Damp Mop ☐Spray Buff ☐Strip, wax, Buff ☐Remove Trash ☐Vacuum ☐Carpet Shampoo ☐Service Restrooms (Clean/Sanitize toilets, urinals, sinks, showers, walls, partitions) ☐Restroom floor cleaning ☐Low Dusting ☐High Dusting ☐Window Cleaning Comments:

Check In/Out:

Vendor Employee(s) Name (print):_________________________________________________

Designated Rep. Person Check In Print Name: ________________________________________ Designated Rep. Person Check Out Print Name: ______________________________________

This Service Ticket shall be filled out by the contracted vendor each time the service provider performs services on location. This service ticket does not provide proof of inspection or acceptance of services. The Government reserves the right to fully inspect work performance of all requirements under contract any time or place it deems necessary.