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COUNTY ROAD 33 & POWERLINE SUBSIDENCE SURVEY <br />• <br /> DATE: j ~ TIME: -1 <br />/S~:'1'~ NAME: ~~ c. /l /~ ~ /~~ <br /> WEATHER CONDITIONS: ~~ <br />,~~.,~N_I PANEL: CJ ~ij~~T <br /> ROAD CONDITIONS YES NO COMMENTS <br /> <br /> CRACKING ti ~Sfr(u <br /> BUCKLING ~ ~„~{ <br /> VISIBLE SETTLING ,/ cf ,~,~'(.r3, ~ ,~ <br /> SINK HOLES , ,~, ~,,« ~ ,~,~~ <br /> OTHER ,~ ~ ~ -. <br /> MAINTENANCE ~r~ ~~,,~( ,~ ~ f~O/au~ ;~ 3SG-~?~, <br /> SHOULDER/FILL CONDITION YES NO COMMENTS <br /> CRACKING ~ <br /> BUCKLING v <br />• VISIBLE SETTLING ;, <br /> SINK HOLES <br />-ff- <br /> OTHER <br />L' <br /> MAINTENANCE <br /> POWERLINE CONDITION YES NO COMMENTS <br /> LINE INTACT t/ <br /> X-ARMS O.K. ~ <br /> CHANGE IN SPAN <br /> POLE TILTING _~~ <br /> OTHER <br /> MAINTENANCE <br /> <br />~4~ <br />e: \documen t\formslsu bside. frm <br />G ;{'~/.-Li/la~ic of ~1 ~~ <br />7 / .~` ~L, <br />~~~ <br />~ 3 m.~-6c <br />~S4 <br />.~ ~fu.15 ~,. <br />V ~ ~~ <br />N C~ <br />06/13196 <br />