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City of Belgrade I Valve Operation Request Form Page 1 of 2 Revised August 2023 Valve Operation Request Date & Time Request Received: Request Received By: Submit Complete Valve Operation Request Form to the Engineering Department via the following: [EMAIL REDACTED] or Hand Deliver to 215 Wings Way, Belgrade, Montana 59714 Requests MUST be received a minimum of two business days in advance of the work being performed. Requestor Information The City of Belgrade will contact the individual listed below to schedule the appointments. Requestor Name: Position: Company Name: Company Mailing Address: Requestor Phone Number: Requestor Email: Site Contact Information Is the site contact information the same as above? No Yes (If yes, the following information may be left blank.) Site Contact Name: Position: Company Name: Site Contact Phone Number: Site Contact Email: Site Information Site Address or Subdivision: Development Phase: Summary of Work Purpose of Request Requested Date of Operation Requested Time of Operation This is NOT the appointment date/time until confirmed by the Public Works Department. 1 : 2 : 3 : 4 : Brief Description of Associated Work Activity: ---PAGE BREAK--- City of Belgrade I Valve Operation Request Form Page 2 of 2 Revised August 2023 The City of Belgrade will determine which valves will be operated. It is the responsibility of the Requestor to clearly describe the work being requested. Failure to do so will result in the request being denied or delayed. Required Attachments Site Plan with Requested Valve Operation Area Highlighted? No Yes N/A Filling, Flushing, & Testing Plan? No Yes N/A Project Engineer Review By: Project Engineer Signature: Date: Company: City of Belgrade Engineering Department Review Authorized Reviewer: Reviewer Signature: Date: No Exceptions Taken Revise & Resubmit Rejected Acknowledgements The main is connected to the City of Belgrade’s Potable Water Distribution System and is full of water – ONLY a City of Belgrade employee who is a certified operator may operate any valve. Permission to have valves operated must be requested. Valve Operation Requests not completed within 24 hours of the date and time of the requested operation shall require resubmittal of a new request with the two business days notification requirement in effect. SHUTDOWNS: (May be left unchecked if not applicable to the requested valve operation.) Where residential and/or commercial services will be affected by the shutdown, the Requestor shall issue pre-printed notice forms to affected customers a minimum of twenty-four (24) hours prior to shutdown. If a shutdown is expected to exceed four hours, as determined by the City of Belgrade, temporary water service will be required. Plans for temporary water service shall be submitted to the City of Belgrade for review and approval. If a shutdown is expected to exceed four hours, as determined by the City of Belgrade, temporary water service will be required. Plans for temporary water service shall be submitted to the City of Belgrade for approval. Flushing operations shall not discharge to sanitary sewers, storm drains, or surface waters. Chlorinated water shall also not be discharged on the ground. (May be left unchecked if not applicable to the requested valve operation.) Verification Checklist Item Contractor Verified Requestor Signature 1. Notices issued to services affected by shutdown 24 hours in advance? Yes No N/A Initial Name: 2. Temporary service being provided if required? Yes No N/A Initial Signature: Date: 3. Notice issued to the Central Valley Fire District where hydrants or fire service lines may be affected by shutdown? Yes No N/A Initial