Kembla Watertech Site Appraisal Form (R1) QF 050-08

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SITE DETAILS

• Line/Asset Number:

• Pipe Material

  Select Concrete Asbestos VC PVC EX Liner Spiral Liner Other

  • Concrete
  • Asbestos
  • VC
  • PVC
  • EX Liner
  • Spiral Liner
  • Other

• Diameter:

• Length:

• U/S Manhole I.D:

• D/S Manhole I.D:

• Work Type

  Select EX Lineing Clean/CCTV SWP Lining Tiger Tee

  • EX Lineing
  • Clean/CCTV
  • SWP Lining
  • Tiger Tee

UPSTREAM Maintenance Hole Location

• Remember to take photos of any useful information. On a regular question you can add media by tapping the question and then taking a photo. Also please remember to be as descriptive as possible.

• Is the manhole located in a residential property?

  Yes

  No

  N/A

• Please supply address.

• Please supply residents Name and contact number.

• Please supply any special request of the resident.

• Is the manhole located on a roadway?

  Yes

  No

  N/A

• Is maned traffic Control required?

  Yes

  No

  N/A

• Will an external traffic control company need to be engaged?

  Yes

  No

  N/A

• Is the manhole considered to be located in difficult terrain?

  Yes

  No

  N/A

• Please supply reason why and a photo.

• Add media

  Media

• Has it been possible to gain access to the Manhole.

  Yes

  No

  N/A

• Please provide information why access could not be gained?

• Is there access to the manhole location for the required equipment?

  Yes

  No

  N/A

• How far is the manhole to the nearest parking position in meters.

• Is the Manhole visible?

  Yes

  No

  N/A

• Is the Manhole buried?

  Yes

  No

  N/A

• What level of Manhole opening equipment is needed?

  Basic lifter

  Gatic lifter (and hand tools)

  hydraulic lifter

• Was the Manhole opened for inspection?

  Yes

  No

  N/A

• Quantity of flow?

  Select 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

  • 0%
  • 10%
  • 20%
  • 30%
  • 40%
  • 50%
  • 60%
  • 70%
  • 80%
  • 90%
  • 100%

• Speed of flow?

  Still

  Slow

  Steady

  Fast

  Heavy

• Does the junction have any droppers?

  Yes

  No

  N/A

• Are there any access arrangements that need to be made before work can commence?

  Yes

  No

  N/A

• Please supply information.

• Has a notification letter been distributed?

  Yes

  No

  N/A

• Date letter was delivered?

  Date

• In the space provided mark the manhole position with an 'X'. Indicate any special hazards, gardens, trees, shrubbery, over head hazards and potential access issues

• U/S Location Diagram if required.

  Drawing

• Add media

  Media

DOWNSTREAM Maintenance Hole Location

• Remember to take photos of any useful information. On a regular question you can add media by tapping the question and then taking a photo. Also please remember to be as descriptive as possible.

• Is the manhole located in a residential property?

  Yes

  No

  N/A

• Please supply address.

• Please supply residents Name and contact number.

• Please supply any special request of the resident.

• Is the manhole located on a roadway?

  Yes

  No

  N/A

• Is maned traffic Control required?

  Yes

  No

  N/A

• Will an external traffic control company need to be engaged?

  Yes

  No

  N/A

• Is the manhole considered to be located in difficult terrain?

  Yes

  No

  N/A

• Please supply reason why and a photo.

• Add media

  Media

• Has it been possible to gain access to the Manhole.

  Yes

  No

  N/A

• Please provide information why access could not be gained?

• Is there access to the manhole location for the required equipment?

  Yes

  No

  N/A

• How far is the manhole to the nearest parking position in meters.

• Is the Manhole visible?

  Yes

  No

  N/A

• Is the Manhole buried?

  Yes

  No

  N/A

• What level of Manhole opening equipment is needed?

  Basic lifter

  Gatic lifter (and hand tools)

  hydraulic lifter

• Was the Manhole opened for inspection?

  Yes

  No

  N/A

• Quantity of flow?

  Select 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

  • 0%
  • 10%
  • 20%
  • 30%
  • 40%
  • 50%
  • 60%
  • 70%
  • 80%
  • 90%
  • 100%

• Speed of flow?

  Still

  Slow

  Steady

  Fast

  Heavy

• Does the junction have any droppers?

  Yes

  No

  N/A

• Are there any access arrangements that need to be made before work can commence?

  Yes

  No

  N/A

• Please supply information.

• Has a notification letter been distributed?

  Yes

  No

  N/A

• Date letter was delivered?

  Date

• Description of Location

• In the space provided mark the manhole position with an 'X'. Indicate any special hazards, gardens, trees, shrubbery, over head hazards and potential access issues

• D/S Location Diagram

  Drawing

• Add media

  Media

COMMENTS

• Site Appraisal conducted by:

  Sign

• Attendees:

  Sign