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2. Application Date
   Application Date
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone
16. Date to Pick Up
    Date to Pick Up
18. Purpose
20. All equipment pick-up and returns located at:
    Waconia Public Services Facility
    310 10th St. E.
    
    Equipment may be obtained between the hours of 7 a.m. – 3 p.m., Monday through Friday.
    
    A $100.00 deposit is required. The deposit will be refunded upon return of all equipment in good condition.
    
    Note: Upon return,equipment may not be left anywhere at the facility without first checking in with city staff. Not checking in may result in the loss of your deposit.
22. Equipment Needed
24. Cones
25. Number Needed
27. Type II Barricades (A-Frame)
28. Number Needed
30. 8-Foot Barricades
31. Number Needed
33. Sandbags
34. Number Needed
36. Flashers
37. Number Needed
39. Construction Fencing
40. Number Needed
42. Posts
43. Number Needed
45. Post Pounder
46. Number Needed
48. Other, specify
49. Number Needed
51. Equipment Return Date
    Equipment Return Date
53. Please Note
    Any lost or damaged equipment will be the responsibility of the company / individual borrowing the equipment. The City of Waconia, or any of its employees, shall not be held responsible for any improperly used equipment that causes injury or damage to property.
55. Signature of Applicant
56. Date
    Date
60. Checked Out By
61. Date
    Date
63. Checked In By
64. Date
    Date
66. 1. Deposit Returned
    2. Billing Required
    3. Missing / Damaged
67. Date Returned
    Date Returned
69. Specify
71. Completed By
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

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