Contact Information

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Client Name

Contact

Address

City

State

Zip

Phone

Email

Fax

Inspection

Date

Time of Inspection

Approx. Temp

Pipe Information - Part 1

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Municipal:

Sanitary (Gravity / Force Main)

Storm

Water

Private Sector

Power

Mining

Refinery

Chemical

Process

Other

CCTV/Video Available:

Yes

No

Attached:

Yes

No

Drawing of Specification:

Yes

No

Attached:

Yes

No

Description:

Type of Pipe:

RCP

PCCP

HDPE

PVC

Carbon Steel

Ductile Iron

SS

CS

VCP

CMP

Aluminium

Other

Material Shape:

Round

Box

Elliptical

Dimensions:

x

Oval

% of Ovality:

(Percent Change of Vertical Deflection over Mean ID of Pipe)

Other

Pipe Information - Part 2

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Thickness of Original Pipe:

in

Current Thickness:

in

Determine if Partially or Fully Deteriorated:

Partially Deteriorated

Fully Deteriorated

Load:

Depth of fill from invert in feet: Access End

ft

Retraction End

ft

Type of fill:

Clay

Sand

Gravel

Stone

Other

Soil Composition Percentage (100%, 90%, 80%):

Density of Soil (lb/ft³):

External Live Loading:

Highway

Railroad

Airplaness

Other

Approx. Surrounding Water Table (Depth in Feet):

Pipe Information - Part 3

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Access:

Manholes (Depth:

ft. / Diameter:

ft.) Chimney (Diameter:

ft. / Length:

ft.)

Ring Diameter:

Pipeline Intrusion Flush?

Yes

No

If protrusion:

in.

Bench?

Yes

No

Flanged Valve Removal

Flanged Pipe Spool Removal

Weld/Re-Weld

Access Points by Others?

Yes

No

Excavation?

Yes

No

Trench Boxes Required?

Yes

No

Approx. Distance Between Access Points

ft.

Pipe Defects:

Cracks:

Longitudinal

Radial

Joints:

Separation

in.

Offset

in.

Lateral Intrusions more than 3/4”

Spawls

(Diameter

in.) Dips (Depth

in.)

Dip Lenght

in. Holes (Diameter

in.

Corrosion

Erosion

Other:

Inflow/Infiltration

Joints

Cracks

Other:

Type of Infil:

Dampness

Weepers

Streams

Approx. GPM:

Effluent Type:

Effluent

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Type (Be specific):

GPM:

% of Capcity:

Time of Day Fluctuations?

Yes

No

Explain:

Ambient:

If not, Temperature:

F

Slurry:

Yes

No

Type:

Velocity:

Pressure:

Yes

No

PSI:

Vacuum:

Yes

No

Mercury:

Design Pressure:

Operating Pressure:

Chemical Composition: Chemical

pH:

%:

Concentration

Use extra lines for all chemicals:

Effluent Composition Schedule Available:

Yes

No

Attached:

Yes

No

Additional comments or concerns:

Logistics/Set Up

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Please provide picture of access and surrounding areas:

Rig Allowed In Facility:

Yes

No

Distance From Pipe Access to Available Rig Location Area:

ft.

Unusual Obstacles:

Yes

No

If yes, explain:

Are there any concerns with hydrocarbons in regard to static ventilating the pipe?

Yes

No

Will the systems need to be bypassed?

Yes

No

Traffic Control Needed?

Yes

No

What Type?

Flaggers

Arrow Boards

Sinage

Additional Comments or Concerns

Problem Description

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Detailed Explanation

Laterals

Size:

Type:

How many in manhole to manhole run:

Joints:

Distance between:

Type:

Max:

Thickness of Originial Pipe(Determine if Partially or Fully Deteriorated):

Additional Notes:

INDUSTRIAL PIPE CLEANING AND CURED-IN-PLACE PIPE REPAIR SERVICES

Contact Information

Page 1 of 7

Inspection

Pipe Information - Part 1

Page 2 of 7

Pipe Information - Part 2

Page 3 of 7

Pipe Information - Part 3

Page 4 of 7

Effluent

Page 5 of 7

Logistics/Set Up

Page 6 of 7

Problem Description

Page 7 of 7

To Contact Us: