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City of Belgrade I Valve Operation Request Form Page 1 of 2 Revised August 2020 Date & Time Request Received: Received By: Pre-Check Completed: Initials Date Public Works Department 91 East Central Avenue Belgrade, MT 59714-3848 Phone: (406) 388-3760 ci.belgrade.mt.us VALVE OPERATION REQUEST FORM VALVE OPERATION REQUEST REQUIREMENTS 1. Contractor shall complete this form in triplicate and submit to the Project Engineer. 2. A map / plan showing the location of valves to be operated by the City of Belgrade is required to be submitted with this form. 3. An incomplete checklist will be cause for delaying the valve shutdown until all requirements are complete. 4. The Project Engineer shall submit the completed request form to the Public Works Department a minimum of 48 hours (2 working days) prior to the time of the desired valve operation by the City of Belgrade. 5. Valve Operation Requests not completed within 24 hours of the date and time of the requested shut down shall require resubmittal of the Valve Operation Request with the 48 hours (2 working days) minimum notification period in effect. 6. Where residential and/or commercial services will be affected by the shutdown, the Contractor shall issue pre-printed notice forms to affected customers a minimum of twenty-four (24) hours prior to shutdown. 7. 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 by the Project Engineer to the City of Belgrade for approval. 8. Flushing operations shall not discharge to sanitary sewers, storm drains, or surface waters. Chlorinated water shall also not be discharged on the ground. VALVE OPERATION REQUEST INFORMATION Project: Location of Valve Operation Request: Purpose of Valve Operation: Date & Time Requested for Shutdown: Estimated Duration of Shutdown: Primary Valves to be Operated (Contractor to Fill-In): Required Map or Plan Attached Project Engineer (Company – Name): Note specific valve locations below for only the number of valves to be operated. Project Engineer Approval Signature: Date: Valve Valve Secondary Valves (For Public Works Use Only): Valve Valve Valve Valve CONTRACTOR INFORMATION Company: On-Site Contact Name: Address: On-Site Contact Phone: On-Site Contact Email: ---PAGE BREAK--- City of Belgrade I Valve Operation Request Form Page 2 of 2 Revised August 2020 ITEMS TO BE COMPLETED PRIOR TO VALVE SHUTDOWN CHECKLIST ITEM CONTRACTOR VERIFIED COMMENTS 1. Notices issued to services affected by shutdown 24 hours in advance? Yes No Initial 2. Temporary service being provided if required? Yes No Initial 3. Notice issued to the Central Valley Fire District where hydrants or fire service lines may be affected by shutdown? Yes No Initial