G Network Street Unit Sign Off Form

• Client / Site

• Install Complete Date

  Date

• Prepared by

• Location
  Address

• INSTRUCTIONS
  
  1. Please answer the questions below.
  2. Add Photos in ""Images"" and Comments in ""Notes"" on each question.
  3. Add a Corrective Measure in ""Action."" Provide a description, assign to a member, set priority, and due date
  4. Complete the audit by providing a digital signature
  5. Share your report by exporting as PDF, Word, Excel or Web Link.

• Number of Laterals

• •Planned

• •Built

FW & CW Measurement From Toby Box

• Number of Toby Boxes

• Yes

  No

  N/A

• •Planned

• •Built

• Number of Chambers

• •Planned

• •Built

• Locations of missing Toby Boxes/FW/CW

• All Ducts (Including laterals) rodded

  Y

  N

• Toby Boxes in Spray Location

• Chamber Types

  Select CW 1 CW 2 CW 3 FW 1 FW 2

  • CW 1
  • CW 2
  • CW 3
  • FW 1
  • FW 2

• Chamber in accessible locations?

  Y

  N

• Reason?

• Depth of Trench & Chamber

• •Trench

• •Chamber

• Chamber and Toby Labels Correct?

  Y

  N

• Number of Trial Holes

• •FW

• •CW

• Uplift Applied Justified?

  25%

  40%

  50%

• All Changes Approved?

  Y

  N

Sign Off

• Signed by Contractor:

  Sign

• Signed by G.Network:

  Sign