W911SA24Q3122 Attachment 1 - DA Form 5457.pdf
Department of the Army Form PDF 127 KB Posted
- Solicitation number
- W911SA24Q3122
About this file
This document is a DA Form 5457, which is used for the Potable Water Container Inspection. It provides a detailed checklist for inspecting various components of potable water trailers and tanks, including the exterior, interior, valves, spigots, and other critical features. The form is divided into sections covering water trailer, water tank truck, fabric tank/drum, and container location (field use) inspections. Key inspection criteria include ensuring the container is marked for "Potable Water Only", checking for cleanliness, rust, gasket/valve integrity, and proper operation of all components. The form provides a comprehensive set of inspection points to ensure the potable water containers meet required standards.
The related federal contract opportunity is a Request for Quotes (RFQ) solicitation numbered W911SA24Q3122 for Water Trailer Sanitation and Potable Water Delivery services at Fort McCoy. The Department of the Army Materiel Command Mission and Installation Contracting Command at Fort McCoy is the awarding agency. The RFQ likely requires the successful contractor to provide potable water delivery and related services, potentially including the use of water trailers and tanks that would need to comply with the inspection criteria detailed in the DA Form 5457.
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Who attaches DA Form 5457
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| File | Type | Posted |
|---|---|---|
| W911SA24Q3122 Solicitation.pdf | ||
| W911SA24Q3122 Attachment 2 - Location Maps.pdf |
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Text version
REPORT DATE
TO FROM
INSPECTION RATING SERIAL NUMBER MAP COORDINATE LOCATION
OWNING UNIT MAINTENANCE NCO UNIT REPRESENTATIVE
INSPECTION UNIT DATE/TIME GROUP INSPECTED BY
POTABLE WATER CONTAINER INSPECTION
For use of this form see TB MED 577; the proponent of this form is the Office of The Surgeon General.
SECTION I. WATER TRAILER INSPECTION CRITERIA
YES
APD LC v1.01ESDA FORM 5457, NOV 2005
SECTION II. WATER TANK TRUCK INSPECTION CRITERIA
Marked "POTABLE WATER ONLY" Clean/Good Repair
Rubber Gasket Intact Locking Mechanism Functions No Rust/Insulation Intact Pressure Relief Valve Operates
All Spigots Function "T" Handle Operates Easily Protective Box Intact Locking Devices Function
Plug Installed Hand-Tight Cracks Do Not Expose Fiberglass Plug/Hole Threads Undamaged Threads Not Rusted
Clean/Good Repair Cracks/Chips Less Than 10% Fiberglass Exposed Paint Surface Not Flaking
Marked "POTABLE WATER ONLY" Clean/Good Repair a.
b.
CONTAINER EXTERIOR1.
Rubber Gaskets Intact Locking Mechanisms Function No Rust/Insulation Intact
2.
Valves Operate Easily Hose Coupling Threads Undamaged Dust Caps Attached to Valve Ports
DISPENSING VALVES3.
Clean/Good Repair No Rust Steel/Aluminum Not Painted
TANK INTERIOR4.
Clean/Good Repair No Rust Not Painted/Coated No Cracks/Dents Exposing
NO
a.
b.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
Polyurethane
MANHOLE COVERS
DISPENSING SPIGOTS
DRAIN
1.
2.
3.
4.
5.
6.
a.
b.
c.
a.
b.
c.
a.
b.
c.
CONTAINER INTERIOR:
STAINLESS STEEL AND
ALUMINUM
CONTAINER INTERIOR:
FIBERGLASS
MANHOLE COVERS AND FILLING
PORTS
CONTAINER EXTERIOR
SIGNATURE:
COMMENTS AND RECOMMENDATIONS:
PRINTED/TYPED NAME AND GRADE OF PVNTMED INSPECTOR:
SECTION III. FABRIC TANK/DRUM INSPECTION CRITERIA
YES
VALVE ASSEMBLY
SECTION IV. CONTAINER LOCATION (FIELD USE) INSPECTION CRITERIA
APD LC v1.01ESREVERSE OF DA FORM 5457, NOV 2005
NO
Marked "POTABLE WATER ONLY" Clean/Good Repair Plugs/Patches Secure a.
b.
c.
Check-Valve Adapter Undamaged Coupler Valve Operates Easily Dust Cap Attached to Coupler a.
b.
c.
CONTAINER EXTERIOR1.
2.
SITE CONDITIONS1.
WATER CONDITIONS2. Chlorine Residual Adequate ( ppm) Procured From:
Spigots
Manholes/Parts Closed Soakage Pits Constructed Beneath a.
b.
a.
b.
REPORT DATE
TO
FROM
INSPECTION RATING
SERIAL NUMBER
MAP COORDINATE LOCATION
OWNING UNIT
MAINTENANCE NCO
UNIT REPRESENTATIVE
INSPECTION UNIT
DATE/TIME GROUP
INSPECTED BY
POTABLE WATER CONTAINER INSPECTION
For use of this form see TB MED 577; the proponent of this form is the Office of The Surgeon General.
SECTION I. WATER TRAILER INSPECTION CRITERIA
YES
APD LC v1.01ES
DA FORM 5457, NOV 2005
SECTION II. WATER TANK TRUCK INSPECTION CRITERIA
Marked "POTABLE WATER ONLY" Clean/Good Repair Rubber Gasket Intact Locking Mechanism Functions No Rust/Insulation Intact Pressure Relief Valve Operates All Spigots Function "T" Handle Operates Easily Protective Box Intact Locking Devices Function Plug Installed Hand-Tight Cracks Do Not Expose Fiberglass Plug/Hole Threads Undamaged Threads Not Rusted Clean/Good Repair Cracks/Chips Less Than 10% Fiberglass Exposed Paint Surface Not Flaking Marked "POTABLE WATER ONLY" Clean/Good Repair a.
b.
CONTAINER EXTERIOR
1.
Rubber Gaskets Intact Locking Mechanisms Function No Rust/Insulation Intact 2.
Valves Operate Easily Hose Coupling Threads Undamaged Dust Caps Attached to Valve Ports
DISPENSING VALVES
3.
Clean/Good Repair No Rust Steel/Aluminum Not Painted
TANK INTERIOR
4.
Clean/Good Repair No Rust Not Painted/Coated No Cracks/Dents Exposing
NO
a.
b.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
Polyurethane
MANHOLE COVERS
DISPENSING SPIGOTS
DRAIN
1.
2.
3.
4.
5.
6.
a.
b.
c.
a.
b.
c.
a.
b.
c.
CONTAINER INTERIOR:
STAINLESS STEEL AND
ALUMINUM
CONTAINER INTERIOR:
FIBERGLASS
MANHOLE COVERS AND FILLING
PORTS
CONTAINER EXTERIOR
SIGNATURE:
COMMENTS AND RECOMMENDATIONS:
PRINTED/TYPED NAME AND GRADE OF PVNTMED INSPECTOR:
SECTION III. FABRIC TANK/DRUM INSPECTION CRITERIA
YES
VALVE ASSEMBLY
SECTION IV. CONTAINER LOCATION (FIELD USE) INSPECTION CRITERIA
APD LC v1.01ES
REVERSE OF DA FORM 5457, NOV 2005
NO
Marked "POTABLE WATER ONLY" Clean/Good Repair Plugs/Patches Secure a.
b.
c.
Check-Valve Adapter Undamaged Coupler Valve Operates Easily Dust Cap Attached to Coupler a.
b.
c.
CONTAINER EXTERIOR
1.
2.
SITE CONDITIONS
1.
WATER CONDITIONS
2.
Chlorine Residual Adequate ( ppm) Procured From:
Spigots Manholes/Parts Closed Soakage Pits Constructed Beneath a.
b.
a.
b.
DA FORM 5457, NOV 2005
APD
POTABLE WATER CONTAINER INSPECTION
1.01
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| signature_BUTTON1: |
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