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SERVICETICKET
WELL CEMENTING
EDWARDE BIRK
3g?,soUTE 16rH
BTIRLINGTON,KS 66839
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62r677s - CELL
620-36+i3r1
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LEASE&
CONTRACTOR
TWP
SEC
KIND OFJOB
DIR TO LOC.
RG
MATERIAL USEI)
QUANTTIY
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BULK CIIARGE
BULKTRIC MILES
PUMP TRK. MILES
PLUGS
TOTAL
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CSG.SET AT
VOLUME
TBG SET AT
VOLUME
MAX. PRESS.
srzF PIPE
PLUGDEPTH
PKERDEPTH
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CEMENTEROR TREATER
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CONCR€TE
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thEPROPERTYOJ
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IhEPURCHASER
UPON
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INSTRUCTIONS
OR CANCELI,ATION
OIORIGINAL
MUSTbE
TELEPHONEO
Io Ih€OFFICE
BEFOSE
TOADING
STARTS.
ne lncsrgnm pfm$ lo paydl cds ncludh!r&son&lea[0me]5is. ncw& 1 ccl&tiq
dy sums0w&
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be4rnle.slallhe6le ol 24{ pe.snLm
Matedalis Delryered.
A $25SeMceCh&geild LN o{ fE CashD6@unlwil be collecied
or ai 3ellmsi Ch*ks
Ex6$ Delay
nmeChdged
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CODE
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TICKET
NUMBER
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PROPEFTY
DAMAGE
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(l'O8ESIGNEO
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INSIDE
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LINE)
Deil CuslomerThs
ddverol thisltuck in pr6enlinglhis nELEASE
to
youlor yoursignatu@
is oJlheopinion
lhalthesizeandweightol his
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dmage to ti6 premises
and/oradjacenl
0l00emn I oac6 neinatenarn Ifls DaowneEvouoesfeil il.s
irr'wlrir tb nAfibO fftvef';av sal we tr. bd ; o'de ro do-rh6
yousgn lhisRELEASE
thedrivefis rcqueslingrlhal
reliryinq
himand
lio6 anydamage
thissupplier
lromey aesponsibility
lhatmayoccuf
to the pfemisesand/oradjacenlpropedy,buildngs,sidewalks
daveways.
curbselc, by lhe delNery
ol lhis malemlandlhalyou
alsoagreelo helphm remove
mudlrcmlhewheeso, hisvehicle
so
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GALX
.WEIGTIMASTER
:an iheundefsigned
agrees
to indemnitandholdhilmless
lhedfver
c1ih6 lruckandlhissupplier
'or anyandalldanagelo lhe premises
propeny
whichhay b6 claimed
&d,or adjacenl
by myoneto have
SIGI.]ED
8Y
LOADRECEIV€D
X
X
DESCRIPTION
PRICE
UNIT
EXTENDED
PRICE
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to pr-lt'rt
LEFT
JOB
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LEFTPLANT
ARRIVED
JOB
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TOTALROUND
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Water
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to Concrete
Performance
HrOAdded
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By
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TOTAL
ATJOB
FINISHUNLOADING
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STARTUNLOADING
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UNLOADING
DELAYEXPI,ANATIONiCYLINDER
TESTIAKEN
1. JOBNOTREAOY
6. TRUCKBROKEDOWN
7, ACCIDENT
2. SLOWPOURORPUMP
3, IRUCKAHEAOONJOE
8. CITATION
4, CONTMCTONBROKEDOWN9 OTHEB
5 ADDEDWATER
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