LARGE PIPE REPAIR REQUEST FORM

Page 1 of 5

Save Form To Continue Later

Tell Us How to Contact You

*Business Name

*Business Address

*City

*State or Province

*Country

Contact Person

*First Name

*Last Name

*Office Phone

*Fax

*Email

Please fill out the following form to the best of your ability. We realize that each situation is unique and requires special attention. By providing detailed information, you are ensuring the clear identification of your precise problem. If you require assistance, please call our offices Monday-Friday 8am-5pm CST.

LARGE PIPE REPAIR REQUEST FORM

Page 2 of 5

Save Form To Continue Later

Pipe Repair Form

1. Dimensions of Pipe

O.D

Wall Thickness

I.D.

% Loss of Wall Thickness

Size of Holes

Estimated SQ FT. of Damaged Area

Spacing of Holes

Pitting

2. Material of Pipe

Steel

Stainless Steel

Carbon Steel

Galvanized Steel

Fiberglass

Other

3. Type of Steel

ASTM - A 36

ASTM - A60

ASTM - 201

Other

LARGE PIPE REPAIR REQUEST FORM

Page 3 of 5

Save Form To Continue Later

4. Operation of Pipe

Operating Pressure

Max Operating Pressure

Surge Pressure

Contents

5. Additional Info

Caustic

External Temp of Line

Leaking/(psi)

Obstructions

Sweating

Temp of Contents

Is shutdown feasible?

Yes

No

Temp of Environment

LARGE PIPE REPAIR REQUEST FORM

Page 4 of 5

Save Form To Continue Later

6. Description: Briefly describe all relevant components that may affect the pipe repair.

(a) Obstructions (i.e. insulation, other pipes, mechanical components etc.)

(b) Valves and Joints (Are there any valves and/or joints that are part of the damaged area?)

(c) Access (Is the pipe above/below grade? Is excavation necessary?)

(d) Depressions (Dimples, divots, etc…)

(e) Additional Info

Please provide a sketch of the pipe structure and indicate the damaged area. Upload a graphic in the following formats: JPEG, PDF, Other.

Select an image file on your computer

LARGE PIPE REPAIR REQUEST FORM

Page 5 of 5

Save Form To Continue Later

Max Temp of Contents

Transient Loads

Min temp of contents

Internal Working Pressure

Operating temp of contents

Internal Transient Pressure

External Dead Load

Superimposed Load

Surge Pressure or Water Hammer

Compressive Strength of Concrete Core

Type of PCCP

OD

Manufacturer of PCCP/Model

Thickness of External Mortar

Corrosion to Steel Can (%)

Gauge of Steel Wire

Pre-stressed Wire Breaks (%)

Thickness of Steel Cylinder

Pipe Weight

Thickness of Concrete Aggregate

Fluid Weight

ID

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

LARGE PIPE REPAIR REQUEST FORM

Page 1 of 5

Tell Us How to Contact You

Contact Person

LARGE PIPE REPAIR REQUEST FORM

Page 2 of 5

Pipe Repair Form

LARGE PIPE REPAIR REQUEST FORM

Page 3 of 5

LARGE PIPE REPAIR REQUEST FORM

Page 4 of 5

LARGE PIPE REPAIR REQUEST FORM

Page 5 of 5

To Contact Us: