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Recifier and Drain Directory Case No.________
Close Interval Survey Notification Form

Case #	County Code	Municipality	Location

Protective System Code	Amps:	Company Code

General Data
Date:
Company:
County: Municipality:
Location of Protected System:
Structure Description:
Companies Involved:
Interference Testing Schedule Date: Time: Place: Date Complete
Rectifier Data
Rectifier Designation: Rated Output- Amps: Volts:
Ground Bed Type & Description:
Operating Output - Amps: Volts: Date:
Mine or Railway Drain Data
SubStation: Owner:
Reverse Current Control: Wire Size: Length:
Operating Drain- Amps (Max): Date:
Bond Data
Structures Bonded: To:
County: Municipality: Date:
Specific Location:
Bond Rating- Amps: Ohms: Type:
Comments: