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2. Site Evaluation to Remove a Streetlight
4. Street Name:
5. Pole No:
6. Requested Date:
   Requested Date:
8. Contact:
9. Phone Number:
10. Evaluation Date:
    Evaluation Date:
14. 1. Are all of the residents living within 500 feet along any road in any direction of this streetlight in agreement regarding removal of this streetlight? (Map and signatures required)

    1. No, request is denied
    2. Yes, proceed to question 2
15. Map and Signatures
17. 2. Is the streetlight one of a group of streetlights that are unusually close to each other? E.g., lamps on 3 poles in a row or lamps within 140 feet of each other?

    1. No, proceed to question 3
    2. Yes, proceed to question 6
19. 3. Is the streetlight in a Special Conservancy, Rural Residential, Water Supply Protection or Farms Forests Rivers zoning district?

    1. No, request is denied
    2. Yes, proceed to question 4
21. 4. Is the streetlight on a busy primary street or a heavily used connector street?

    1. Yes, request is denied
    2. No, proceed to question 5
23. 5. Are there more than 3 residential residences within 150 feet of the light?

    1. Yes, request is denied
    2. No, proceed to question 6
25. 6. Is the streetlight illuminating any potential road or traffic hazard such as an intersection, a crosswalk, a school zone, a fire station, etc. or are there other factors or special conditions to take into consideration such as the streetlight is illuminating a wheelchair way, etc.?

    1. Yes, request is denied. Indicate reason:______________________________________________________________
    2. No, request is approved
29. Request is
30. Budget Acct.
    11922-521002
32. Capital Cost to Remove Light
33. Funding Available
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

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