South Gate Middle School


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	Request for Repair/Replacement of Equipment Please fill out the appropriate section as needed. Mandatory fields marked * Date * Teacher Name * Room # * Room Ext. # * Facilities Conditions (choose as many as apply) Room Lights Specify # Light Covers Specify # Graffiti Location Telephone Repair Incoming Calls Outgoing Calls Gas Leak Broken windows Broken exterior doors Gates that will not lock and that pose a security risk Abatement of hazardous materials previously undiscovered that pose an immediate threat to pupil of staff Structural damage creating a hazardous or uninhabitable condition Non-functioning air conditioning system Non-functioning heating system Non-functioning ventilation system Non-functioning fire sprinklers Major sewer line stoppage Major pest or vermin infestation Termites Ants Cat Other Room maintenance needs Mopped Swept Waste Removal Description of Specific Need Equipment Needs (choose as many as apply) Student Chairs Specify # Student Desk (Combination chair/desk) Specify # Table (Student desk table) Specify # Other Specify Size Specify # Teacher Chair Teacher Desk Description of Specific Need