GROUND LEVEL POLY TANK INSPECTION REPORT

Water System Name & Number:

Station/Tank Name:	Date:

Design Capacity:	Effective Capacity:

Last Inspection Date:	Inspection Frequency:

Last Drained & Cleaned Date:	Next Scheduled Cleaned Date:

SECURITY	YES	NO	N/A	Comments
Signs of trespassing or vandalism?
Fence, cage and/or access ladder locked?
Access hatch sealed properly and locked?
Ability to bypass?
Tank operations linked to SCADA?
Water level gauge within 10% of SCADA reading?

OVERFLOW PIPE	YES	NO	N/A	Comments
Overflow discharge pipe screened?
Overflow discharge pipe equipped with an air-gap?

ROOF AIR VENTS	YES	NO	N/A	Comments
Roof air vents screened?
Roof air vents turned down or covered?

EXTERIOR ROOF	YES	NO	N/A	Comments
Holes or openings in roof?
Depressions in the roof structure?
Ponding water?
Fungi or other vegetative growth?
Excessive dirt or debris?
Other damages to structure?

EXTERIOR SIDE SHELL	YES	NO	N/A	Comments
Holes or openings in the side shell?
Buckles or depressions in shell structure?
Other damages to structure?

INTERIOR SIDE SHELL, FLOOR & LADDER	YES	NO	N/A	Comments
Coating cracked or peeled?
Sediment deposits on side shell, floor and/or ladder?
Other damages to structure?
Last interior inspection date:
TREES AND VEGETATION	YES	NO	N/A	Comments
Overhanging tree limbs?

FINISHED WATER SUPPLY	YES	NO	N/A	Comments
Dust, debris and/or floaters?
Odor?
Oil on surface?
Free and/or total chlorine residual level:

OVERALL CONDITION OF TANK:	POOR	GOOD	EXCELLENT

DOCUMENTS AVAILABLE:	AS-BUILT PLANS PHOTO/VIDEO O/M RECORDS LAT/LONG

PHOTOS – Please see attached document for the types of photos to include.

COMMENTS & RECOMMENDATIONS:

Inspector Name & Title:

Inspector Signature & Date:

Form provided to:	Division of Drinking Water District Office