QC Report Template 1

• Conducted on

  Date

• Prepared by

• Location
  Address

ARRIVAL STATUS

• Is the catch basin cover clean?

  Yes

  No

  N/A

• Is the catch basin cover damaged?

  Yes

  No

  N/A

• Is the catch basin (sub-surface walls ((concrete/brick)) damaged?

  Yes

  No

  N/A

• Is there standing water at this catch basin location?

  Yes

  No

  N/A

CATCH BASIN COVER INSPECTION

• Does the catch basin cover require cleaning?

  Yes

  No

  N/A

• If the catch basin COVER is not 100% clean, list what is visible on the catch basin cover

  Select Grass clippings Twigs/branches/sticks Soil/sand/gravel/rocks Weeds growing Trash/Debris (non-hazardous) Hazardous debris Vehicle parts Mardi Gras Beads Used Fireworks debris Other

  • Grass clippings
  • Twigs/branches/sticks
  • Soil/sand/gravel/rocks
  • Weeds growing
  • Trash/Debris (non-hazardous)
  • Hazardous debris
  • Vehicle parts
  • Mardi Gras Beads
  • Used Fireworks debris
  • Other

CATCH BASIN (SUB-SURFACE) INSPECTION

• Is the catch basin clean of all debris?

  Yes

  No

  N/A

• If not 100% clean, what is visible inside the catch basin?

  leaves

  twigs/branches/sticks

  trash/debris

  hazardous materials

  Filled with water

• Is the drain pipe(s) visible inside the catch basin?

  Yes

  No

  N/A

HAZARDOUS MATERIALS

• List all hazardous materials present on catch basin cover and inside catch basin

  Select Broken glass Syringe Oil container Gas container Propane tank Sharp metal object Vehicle parts Tire Drug paraphanalia

  • Broken glass
  • Syringe
  • Oil container
  • Gas container
  • Propane tank
  • Sharp metal object
  • Vehicle parts
  • Tire
  • Drug paraphanalia

Homeowner/Tenant Questions

• Has the homeowner/tenant called 311 to notify the city that the catch basin is clogged?

  Yes

  No

  N/A

• If yes, what is the 311 reference number?

• When did the homeowner/tenant call 311?

  Date

• Does the homeowner clean the catch basin and/or catch basin cover themselves?

  Yes

  No

  N/A

BEFORE PHOTOS -CATCH BASIN COVER

• Before Photo 1

  Media

• Before Photo 2

  Media

• Before Photo 3

  Media

AFTER PHOTOS - CATCH BASIN COVER

• After Photo 1

  Media

• After Photo 2

  Media

• After Photo 3

  Media

CATCH BASIN (SUB-SURFACE) PHOTOS

• Photo of Catch basin 1

  Media

• Photo of Catch basin 2

  Media