Attachment 11_5 Basic Inspections Form.pdf

ATTACHMENT 1.5 BASIC INSPECTIONS FORM

Use space below to document observed needs for repairs and maintenance

Note any cracks, missing or broken components, graffiti, and other vandalism.

TOILET BUILDING EXTERIOR

Roof

Ventilation Stack

Walls, including vent cover

Foundation/Slab/Apron

Door and door handle

Signage (present or missing)

TOILET BUILDING INTERIOR

Floor

Walls, including vent cover

Foundation/Slab/Apron

Door and door handle

Toilet Seat and riser condition

Toilet Paper Dispenser (if present)

Signage (present or missing)

SUBSURFACE COMPONENT (Vault or septic system etc.)

Perform a basic inspection of the vault or subsurface structure. Enter N/A if not applicable.

1st Compartment

2nd Compartment

Inlet baffle condition OR access port to vault

Outlet Baffle condition

Effluent baffle screen condition

Total Tank Capacity

Total Gallons pumped

Depth of Scum

Depth of Sludge

Vault tank material type

Access to tank port

General Comments:

Inspection Certification

I verify that the information listed herein is true and accurate to the best of my knowledge, belief, and observation.

Inspection Performed by:

Contractor Name:______________________________ Date:_____________________________

Address:______________________________________ Phone:____________________________

Email:____________________________________________________________________________