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City of Belgrade I Valve OperaƟon Request Form Page 1 of 2 Revised June 2024 VALVE OPERATION REQUEST Date/Time Received: Received By: Submit completed Valve Operation Request forms to the Public Works Department via the following: [EMAIL REDACTED] or deliver to 621 Lagoon Rd, Belgrade, MT 59714. Requests MUST be received a minimum of two business days in advance of the work being performed. Forms received after 12:00 pm will not be processed until the following day. 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 Belgrade Public Works. 1 : 2 : 3 : 4 : Brief Description of Associated Work Activity: ---PAGE BREAK--- City of Belgrade I Valve OperaƟon Request Form Page 2 of 2 Revised June 2024 The Project Engineer may propose valves to be operated, but the Public Works Department will make the final determination. 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 Public Works 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 Belgrade Public Works 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 eƯect. SHUTDOWNS: (May be left unchecked if not applicable to the requested valve operation.) Where residential and/or commercial services will be aƯected by the shutdown, the Requestor shall issue pre-printed notice forms to aƯected customers a minimum of twenty-four (24) hours prior to shut down. 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 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 aƯected 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 aƯected by shutdown? Yes No N/A Initial SIGN SIGN SIGN