Maintenance Request Form

• Request Number

• Date and Time of Maintenace Request

  Date

• Site

  Select Beverley Boddington Darkan Narembeen Pingelly Quairading Williams

  • Beverley
  • Boddington
  • Darkan
  • Narembeen
  • Pingelly
  • Quairading
  • Williams

• Specific Location

  Select Bathrooms - Male Bathrooms - Female Baby Pool Learner Pool 50M Pool 50M Pool - North Side 50M Pool - South Side Grandstand Pump Room Balance Tank Waste Tank North lawn South lawn Kiosk Front area Main Paths - Inside Main Paths - Outside

  • Bathrooms - Male
  • Bathrooms - Female
  • Baby Pool
  • Learner Pool
  • 50M Pool
  • 50M Pool - North Side
  • 50M Pool - South Side
  • Grandstand
  • Pump Room
  • Balance Tank
  • Waste Tank
  • North lawn
  • South lawn
  • Kiosk
  • Front area
  • Main Paths - Inside
  • Main Paths - Outside

• Description of defect (give as much detial as possible)

• Photo of Defect (Multiple Photos can be attached)

  Media

• Include Part Numbers & Model numbers if avaliable

  Media

Maintenance Request Form

• AN INCIDENT FORM MUST BE COMPLETED IF THE FAULT HAD POTENTIAL TO CAUSE INJURY OR ENVIRONMENTAL DAMAGE

• Can item be safely used until repaired?

  Yes

  No

• Note: Affix OUT OF SERVICE tag and follow procedures.

• Does the item require servicing?

  No

  Yes

  No - Replacement

• Is an incident form required for this issue?

  Yes

  No

Incident Report Form

• Person completing the form

  Kylie Casey

  Clinton Cheney

• Is training required to fix this problem?

  No

  Yes

  No - Replacement

• Describe

• Has chemical residue been removed to enable safe servicing?

  Yes

  No

  N/A

• Please thoroughly clean all chemical residue prior to servicing

• Description of the problem (besides “not working”)

• Cause

• The above defect form has been completed to the best of my ability

  Sign