Title Page

  • Line Number

  • Interflow Reference

  • Line Diameter (as per supplied info)

  • Line length (as per supplied info)

  • Junctions (as per supplied info)

  • Conducted on

  • Prepared by

  • Location

US Manhole

  • Manhole Number

  • Access location

  • Details

  • Was the manhole able to be located?

  • Is the location and other information on the supplied map accurate?

  • What are the inaccuracies?

  • Type of Access

  • Details

  • Type of manhole

  • Details

  • Is a Dig-up Required?

  • Dig-Up Details

  • Rehabilitation Required

  • Difficulty categories
    1/Manhole on road. Kubota can work from the back of the truck.
    2/ MH invert less than 20m from truck. Kubota able to work over manhole.
    3/ MH invert over 20m from truck. Kubota able to work over manhole.
    4/ Winder must be manually handled to a distance (from invert) less than 20m from Kubota -Unable to work over manhole. Assess profile flow and manning requirements.
    5/ Winder must be manually handled to a distance (from invert) greater than 20m from Kubota -Unable to work over manhole. Assess profile flow and manning requirements.
    6/ Difficult Terrain. Category 5+ environmentally sensitive &/or extra equipment required. eg. cranes, scaffolding, flying foxes, barge. Take Photos, determine manning requirements.

  • Difficulty Category

  • Profile Handling distance?

  • Number of extra people required?

  • Extra Equipment required? (eg. Flying Fox, Barge, Crane)

  • Condition of Manhole and Lid? (1= Requires immediate works, 5= No works required)

  • Works Required?

  • Depth to invert?

  • Jackout Estimates
    0= No jackout ie. easily accessed dropper
    1= Under 30 mins. ie, Retic lines with slight to no bends in channel
    2= 30-60 mins. ie, Retic lines with large bends or straight through carriers (up to DN450)
    3= 60 mins +. ie, Carriers with bends in channel or over DN450

  • Jackout Requirements?

  • Extra equipment recommended? (eg. Air operated demo saw, High pressure water lance, 90 pound Jackhammer)

  • Manhole width? (Width of inside the manhole, not the manhole neck)

  • Shallow manholes with a width of less than 1m are likely to require the removal of the aspro to complete lining works.

  • Is the removal of the aspro recommended to complete lining?

  • Photos of Manhole and surrounding area?

  • Unable to be located because of

  • Were you able to locate by probing?

  • Photo with probe over buried manhole

  • Photos of the estimated location and surrounding area

  • Address

  • Property Details

  • Property identification photos. Eg. business signs with numbers

  • Property type

  • Details

  • Park Name

  • Photos of the area

  • Details

DS Manhole

  • Manhole Number

  • Access location

  • Details

  • Was the manhole able to be located?

  • Is the location and other information on the supplied map accurate?

  • What are the inaccuracies?

  • Type of Access

  • Details

  • Type of manhole

  • Details

  • Is a Dig-up Required?

  • Dig-Up Details

  • Rehabilitation Required

  • Difficulty categories
    1/Manhole on road. Kubota can work from the back of the truck.
    2/ MH invert less than 20m from truck. Kubota able to work over manhole.
    3/ MH invert over 20m from truck. Kubota able to work over manhole.
    4/ Winder must be manually handled to a distance (from invert) less than 20m from Kubota -Unable to work over manhole. Assess profile flow and manning requirements.
    5/ Winder must be manually handled to a distance (from invert) greater than 20m from Kubota -Unable to work over manhole. Assess profile flow and manning requirements.
    6/ Difficult Terrain. Category 5+ environmentally sensitive &/or extra equipment required. eg. cranes, scaffolding, flying foxes, barge. Take Photos, determine manning requirements.

  • Difficulty Category

  • Profile Handling distance?

  • Number of extra people required?

  • Extra Equipment required? (eg. Flying Fox, Barge, Crane)

  • Condition of Manhole and Lid? (1= Requires immediate works, 5= No works required)

  • Works Required?

  • Depth to invert?

  • Jackout Requirements?

  • Extra equipment recommended? (eg. Air operated demo saw, High pressure water lance, 90 pound Jackhammer)

  • Manhole width? (Width of inside the manhole, not the manhole neck)

  • Shallow manholes with a width of less than 1m are likely to require the removal of the aspro to complete lining works.

  • Is the removal of the aspro recommended to complete lining?

  • Jackout Estimates
    0= No jackout ie. easily accessed dropper
    1= Under 30 mins. ie, Retic lines with slight to no bends in channel
    2= 30-60 mins. ie, Retic lines with large bends or straight through carriers (up to DN450)
    3= 60 mins +. ie, Carriers with bends in channel or over DN450

  • Photos of Manhole and surrounding area?

  • Unable to be located because of

  • Were you able to locate by probing?

  • Photo with probe over buried manhole

  • Photos of the estimated location and surrounding area

  • Address

  • Property Details

  • Property identification photos. Eg. business signs with numbers

  • Property type

  • Details

  • Photos of the area

  • Details

Traffic / Access

  • Are there any nearby services that may be affected by the works?

  • Details

  • Will any vehicle be located on a roadway for work?

  • within 100m of any of the following?

  • Traffic Volume? (1=Light, 2=Medium, 3=Heavy)

  • Road Type?

  • Road Authority?

  • Road Width?

  • Speed Limit?

  • Management type?

  • Will works be affecting any pathways?

  • Pedestrian Volume? (1=Light, 2=Medium, 3=Heavy)

  • Will a park permit be required to complete the works?

  • Name of Park?

  • Impact to park?

  • Other Details

Resident Information

  • Number of affected customers? (the number of houses connected to the line, or houses on the street if works will be impacting the traffic conditions)

  • Add impacted Resident contact information.
  • Address
  • Customers Name

  • Contact Number

  • Email address

  • Impact to property?

  • Property impacts?

  • Details

Risks / Hazards

  • Are any of the following environmental risks present?

  • Details

  • Are any of the following hazards present?

  • Details

Flow Control

  • Date and Time

  • Flow level percentage?

  • Is the line affected by a pump station?

  • Recommended flow control measures?

Assumptions

  • Please note any assumptions that have been made within this form? (ie. Depth of buried manholes, Manholes located on inaccessible properties not buried etc.)

Condition of Area

  • Any existing damage to the surrounding area to be taken note of?

  • Photos of existing damage

Sketch

  • Recommended winding direction?

  • Sketch of the area

Completion

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.