Sweep Service Form Sweep Service Form Customer* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Assessor*KimTylerBlakeDate* MM slash DD slash YYYY Billing InformationNew Customer* Yes No No Show Fee* Yes No Sweep, # of flues*012345678910Direct connect/Rotary, # of flues*012345678910Video Scan, # of flues*012345678910Inspection/Assessment* Yes No Safety Equipment Fee*Trip Charge (miles < 20)* Materials*Follow-up/Recommendations*Time In* : Hours Minutes AM PM AM/PM Time Out* : Hours Minutes AM PM AM/PM Fireplace LocationA. Firebox Height at Front (inches)* B. Firebox Width at Front (inches)* C. Firebox Width at Rear (inches)* D. Firebox Depth at Bottom (inches)* E. Firebox Depth at 20" H (inches)*