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Work Order Request Form
Your Contact Information
Contact Email *
Contact First Name*
Contact Last Name*
Phone Number*
Maintenance Information
Building *
Select One
401-15 County Administration - Estancia
401-16 Judicial Complex/Sheriff/DA - Estancia
401-23 Mountainiar Health Clinic
401-24 Health Department/TCPO - Estancia
401-27 Mountainair Senior Center
401-36 Estancia Senior Center
401-37 Moriarty Senior Center
401-85 Animal Services - Mcintosh
412-53 County Fairgrounds - Estancia
431-91 Fire Administration - Estancia
630-87 Esperanza Health Center - Estancia
911-80 Dispatch Center - Mcintosh
Floor Level of Building*
Room# or Area of Building*
Description of Requested Services*
Category of Requested Services*
This request is related to a finding from a semi-annual safety inspection, reported to the Risk Management Division
This request is related to an incident that will be or has been reported to the Risk Management Division
This request is NOT related to a safety inspection finding or incident
Problem Code*
Select One
ACCESS CARD - NEW EMPLOYEE, REPLACEMENT, REASSIGNMENT, TERMINATION, CARD READER NOT WORKING
CEILING TILE REPLACEMENT
DOOR ADA INOPERATIVE
DOOR INOPERATIVE
DOOR KEY - NEW EMPLOYEE, REPLACEMENT, REASSIGNMENT, TERMINATION
ELEVATOR DOES NOT WORK, NON-EMERGENCY
FLOODS (INDOOR OR OUTDOOR - IMMINENT DAMAGE TO STATE PROPERTY)
HANGING PICTURES, WHITEBOARDS, ETC.
HAZARD (SLIP/TRIP/FALL/PINCH/CUT HAZARD)
ICE/SNOW REMOVAL
IRRIGATION (NOT WORKING, BROKEN SPRINKLER HEAD, ETC.)
LANDSCAPE/GROUNDS (BROKEN TREE LIMBS, MOWING, DEBRIS, ETC.)
LEAK (CEILING, WALL, WINDOW, DOOR, PLUMBING, IRRIGATION)
LIGHTING (LIGHT OUT, REPLACE LIGHTS, DIM LIGHTS, FLICKERING)
NON-EMERGENCY (POTENTIAL RISK TO LIFE SAFETY)
PATCH AND PAINT
PEST CONTROL (RODENTS, INSECTS, REPTILES, BATS, ETC.)
PLUMBING (NO WATER, HOT WATER, TOILET/URINAL/SHOWER NOT FLUSHING OR STOPPED UP)
POWER OUT (LOSS OF WALL OUTLET POWER/BREAKER TRIPPED, LOSS OF BUILDING POWER)
SIGNAGE - EXTERIOR (NEW INSTALL, REPLACEMENT, RELOCATION)
SIGNAGE - INTERIOR (NEW INSTALL, REPLACEMENT, RELOCATION)
SMELLS (GAS, SEWER, TRASH, ELECTRICAL)
TOO HOT/COLD
TRASH - EXTERIOR
TRASH - INTERIOR
VANDALISM - EXTERIOR
VANDALISM - INTERIOR
Desired Date
General Information
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Road Maintenance Request Form
Sign Request Form
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