SMOKE TESTING INSPECTION REPORT

• Conducted on

  Date

• Prepared by

• Location
  Address

• Client

• Project Code

• Main Asset #

• PASS OR FAIL

  Pass

  Fail

  N/A

• Comments/Observations

• Photo of Inspection

  Media

• Downstream MH #

• PASS OR FAIL

  Pass

  Fail

  N/A

• Comments/Observations

• Photo of Inspection

  Media

• Upstream MH #

• PASS OR FAIL

  Pass

  Fail

  N/A

• Comments/Observations

• Photo of Inspection

  Media

HOUSE/PROPERTY INSPECTION 1

• Street Address
  Address

• Inspection completed

  Yes

  No

  N/A

• PASS OR FAIL

  Pass

  Fail

  N/A

• IO in good condition, sealed & above ground

  Yes

  No

  N/A

• Overflow Relief gully in Good condition & above gground

  Yes

  No

  N/A

• Broken pipes identified

  Yes

  No

  N/A

• Roof discharge plumbed correctly

  Yes

  No

  N/A

• Runoff discharge directed to stormwater (kerb & gutter)

  Yes

  No

  N/A

• Comments/Observations

• Photo of inspection

  Media

HOUSE/PROPERTY INSPECTION 2

• Street Address
  Address

• Inspection completed

  Yes

  No

  N/A

• PASS OR FAIL

  Pass

  Fail

  N/A

• IO in good condition, sealed & above ground

  Yes

  No

  N/A

• Overflow Relief gully in Good condition & above gground

  Yes

  No

  N/A

• Broken pipes identified

  Yes

  No

  N/A

• Roof discharge plumbed correctly

  Yes

  No

  N/A

• Runoff discharge directed to stormwater (kerb & gutter)

  Yes

  No

  N/A

• Comments/Observations

• Photo of inspection

  Media

HOUSE/PROPERTY INSPECTION 3

• Street Address
  Address

• Inspection completed

  Yes

  No

  N/A

• PASS OR FAIL

  Pass

  Fail

  N/A

• IO in good condition, sealed & above ground

  Yes

  No

  N/A

• Overflow Relief gully in Good condition & above gground

  Yes

  No

  N/A

• Broken pipes identified

  Yes

  No

  N/A

• Roof discharge plumbed correctly

  Yes

  No

  N/A

• Runoff discharge directed to stormwater (kerb & gutter)

  Yes

  No

  N/A

• Comments/Observations

• Photo of inspection

  Media

HOUSE/PROPERTY INSPECTION 4

• Street Address
  Address

• Inspection completed

  Yes

  No

  N/A

• PASS OR FAIL

  Pass

  Fail

  N/A

• IO in good condition, sealed & above ground

  Yes

  No

  N/A

• Overflow Relief gully in Good condition & above gground

  Yes

  No

  N/A

• Broken pipes identified

  Yes

  No

  N/A

• Roof discharge plumbed correctly

  Yes

  No

  N/A

• Runoff discharge directed to stormwater (kerb & gutter)

  Yes

  No

  N/A

• Comments/Observations

• Photo of inspection

  Media

HOUSE/PROPERTY INSPECTION 5

• Street Address
  Address

• Inspection completed

  Yes

  No

  N/A

• PASS OR FAIL

  Pass

  Fail

  N/A

• IO in good condition, sealed & above ground

  Yes

  No

  N/A

• Overflow Relief gully in Good condition & above gground

  Yes

  No

  N/A

• Broken pipes identified

  Yes

  No

  N/A

• Roof discharge plumbed correctly

  Yes

  No

  N/A

• Runoff discharge directed to stormwater (kerb & gutter)

  Yes

  No

  N/A

• Comments/Observations

• Photo of inspection

  Media

• Signature

  Sign