Title Page

  • Time & Date:

  • Contract

  • Site

  • Location
  • Completed by:

  • Job/Ticket No.

  • PIA NOI Number

  • Annotated map marking blockage location with a red X

A55

Chamber 1

  • Chamber 1 location:
  • Chamber 1 description:

  • Easting and Northings (From BT portal)

  • Surface type:

  • Photo(s) of chamber 1 set up: (including barriers)

  • Rods used:

  • Photo(s) of 25mm rods in bore (Geo-tagged and time-stamped) :

  • Number of Bores:

  • Number of cables currently in bore:

  • Current capacity of bore:

  • BT Duct Reference ( e.g. 1479 - R, found on work pack map):

  • How far is the blockage from chamber 1? (in metres):

  • Any additional comments?

  • Any additional photos?

  • Blockage Details
  • Please complete blockage details and provide location and photo evidence in the sections below. If there are multiple blockages in one location, please put them on this form. The button looks like this:

    bl.png
  • Total distance of section

  • Photo of blockage: (please spray a X and on blockage)

  • Location Details (please drop a pin on the blockage)
  • Please take a photo of the house/property/defining features nearest the blockage: (helps us to find it, if the location pin is incorrect)

Chamber 2

  • Location of chamber 2:
  • Chamber 2 description:

  • Easting and Northings (From BT portal)

  • Surface type:

  • Photo(s) of chamber 2 set up: (including barriers)

  • Rods used:

  • Photo(s) of 25mm rods in bore (Geo-tagged and time-stamped) :

  • Number of bores:

  • Number of cables currently in bore:

  • Current capacity of bore:

  • BT Duct Reference (e.g. 1479 - R):

  • How far is the blockage from chamber 2? (in metres):

  • Any additional comments:

  • Any additional photos:

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