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--- ---- - - ---- � <br /> 2013 LA.P.GE STORM RESPONSE PAPER FORM CHECKLIST <br /> � <br /> '' -- <br /> I� Dateolinspection�. � � �__ InSpecled8y.�� �l+✓1 . <br /> Address�_���1 �// � � /� �i Servicr.Reques�Num6er ____ .___._____ <br /> Resident O���ner? ❑YES ❑NO <br /> i <br /> PhoneNumber. _Email: _____ _. __._ <br /> � General 6uilA�ng Details: ; <br /> i <br /> , Is Ihls 6wlding�vith�n Ihe combined sev:zr area9 �YcS ❑D!0 Does the buiiding have a basement7 YES ❑NO <br /> Does Ihe bultd�ng havc a ba�kwaler valve(61tiV)? �YES �NO pt yes)Was BWV msla9ed ihiough Ciry progiam �YES �'NO <br /> ' �oes Uie bwldmg haae a sump pump7 �YE�NO Ooes ihe 6ui!dmg have a grinder pump7 �YES�tJO ' <br /> I Slorm Evml Delads: <br /> I Wnere did water entering huilding come from� ❑SURFAGE FLOW ❑GROUNDWATER SEWER BACKUP-PIRTURES ❑UNKNON'N . <br /> iDelails�.�f_�.��7� t //J��� - <br /> �� VJheredidtealergov:ith:ntnebudding? �4SERSENTP[RIMETER L'��ASEId[NTNEARFIXTURES �OTHER <br /> IDelails�.�� � }��n/ 'j _ <br /> I I <br /> � SileOhservalions� <br /> Dawnspou!1 sile graAlnq issues�oled.�/i�n���� � � I�G+�-,1 — <br /> � Butltlmg eleval�on rr.lalive to sewer and surro�.:nding areq issues noted: - <br /> �i Site purnp issues notcA: <br /> � Hisloricallnformatwn/0lhcrintoimation� <br /> ' � /�" ���1� � ' 1 GlG <br /> Previous"Iloodin9 issue5erviceRequcslsataddresa�n�C'Y�' (,r��J'4)/�� /(lJi � �r�' 1 �-'- �t �- <br /> � Picvious°Ilaoding'i:sucs noi.A 6y homeow.nec_� �� � ^ ��� � <br /> ftecent slormwaler/sewer pro�ecls compleled in area Se�������oposed sionnvia!er I sewer pwjecls in are . <br /> Pr�;edy owner iNerested in be9inning Cdy�ackv.�ater Valve Program al address� YES ❑NO �etails� <br /> Noles:L,���i 6�Gr����PSfP 4c�� �C�1vU �c!.SI ���''.n'n� <br /> ��l"'j �—f dU� ��� . �A /1,�i����F%rl //�i/� � -- <br /> I <br /> I <br /> iRevision:3 TRW 1 Thursday,Scptember O5,2013 <br /> i <br /> � <br />