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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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CITY/
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Comtt.Y
COUNTY
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cHARGErctrlll(rf((lzirL
ADDRESS
LEASE&
CONTRACTOR
TWP
SEC
KIND OFJOB
DIR TO LOC.
RG
MATERIAL USEI)
QUANTTIY
](n s
SERV.CHG
)rl- lArf,l Ornrrrl
BULK CIIARGE
BULKTRIC MILES
PUMP TRK. MILES
PLUGS
TOTAL
," 1870',
t'
CSG.SET AT
VOLUME
TBG SET AT
VOLUME
MAX. PRESS.
srzF PIPE
PLUGDEPTH
PKERDEPTH
srnHoLEb 3/4
CEMENTEROR TREATER
PLUGUSED
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s :^_ f,:*!- :-s:a :s ,f;., a: a*-e-s or inlemediary'sdir€ction,
_: -*:a_s a ^{ 'a' aa.ages :r a.y manner to sidewalks,
se 9' s-_?s
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: ,9^a,! :- :-;s -9es s--,:*J
ei:, *h'ch &e at customoas
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tor
cts, Inc.
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:ai i-:se reEcrs slpplyingmaterialor sewicesto
::-a e'a :_ a aa"'z: aa' '?s-: _ :fe f:rrg oi a nechanrcslienon the proporty
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COOF'ERAT
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LOAD
#
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CONCR€TE
6 APERISHABLE
thEPROPERTYOJ
COMMODITf
ANdBECOMES
IhEPURCHASER
UPON
LEAVING
IhE PLANT.ANYCHANGES
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&
Aliacc@nhnotpaijwilhh3,0&ys ol deliwrywll
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
@tsoAlR.
CODE
'i ;,i. i,liit
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r y l + : f r $ j ";,i\ . , ' , - , r l : , 1i i j j l i l , i i : :
1i l i , r , i l , l
d
fill ' i:l liil ti
i/ir
YARDS
DEL,
PLANT/TRANSACTIO.N
#
DRIVER/IRUCK
: i
r;:l
BATCH#
TRIM
WATER
TICKET
NUMBER
SLUMP
'I i'ri. ;::i_':
i1'r: |-,r
OUANTITY
YARDS
ORDERED
itri i
DA'IE
'i
LOADSIZE
1,"
'.:
iitit!
PROPEFTY
DAMAGE
RETTASE
(l'O8ESIGNEO
BEMADE
IFOEUVERYTO
INSIDE
CURB
LINE)
Deil CuslomerThs
ddverol thisltuck in pr6enlinglhis nELEASE
to
youlor yoursignatu@
is oJlheopinion
lhalthesizeandweightol his
ltuckmaypo$ibly@u.se
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
,'"'lrji
i ri
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
i - : 1I i
' : :!:'i:
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,'/ , '-"'''*
#
Hetunrueo
to pr-lt'rt
LEFT
JOB
A '1 3
5i r/t)
LEFTPLANT
ARRIVED
JOB
a ' ' l YI
,'r(.r"-:(
TOTALROUND
TRIP
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j
Excessive
Water
is Detiimental
to Concrete
Performance
HrOAdded
ByRequest/Authorized
By
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{ , ,t.i,;;
TOTAL
ATJOB
FINISHUNLOADING
5,'3a)
STARTUNLOADING
7',r(,
TIIVE
UNLOADING
DELAYEXPI,ANATIONiCYLINDER
TESTIAKEN
1. JOBNOTREAOY
6. TRUCKBROKEDOWN
7, ACCIDENT
2. SLOWPOURORPUMP
3, IRUCKAHEAOONJOE
8. CITATION
4, CONTMCTONBROKEDOWN9 OTHEB
5 ADDEDWATER
TltvlEALL0WED
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J r
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TII/E DUE
ADDITIONAL
CHARGE
1
DELAY
TIi/E
t,lft
ADDITIONAL
CHARGE2
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