INSPECTION REPORT Date : _________________

Page. ________ of _______

UNDERGROUND PIPING CHECK
Rev. : _________________

Project Name : _______________________________ Owner : __________________________________

Application For Inspection No. : _____________________________________________

Dwg / Line No. : Location :

Result
Item Description Remark
Accept Reject
1 Formation Surface Condition
2 Formation Level Correct
3 Pipe Level Correct
4 Supports Installed
5 Holiday Test
6 Installed to Drawings
7 N.D.E. Complete
8 Visual
9 Clean Out
10 Partial Backfill for Anchors
11 Hydro Test or N.D.E. Field Welds
12 Wrapping Joints and Holiday Test
13 Flushing
14 Backfill Completely
15 Others

Comments :

Sub-Contractor Repco Owner

Inspection or Witness FW/I FW RW

Signature :

Name :

PC-ME-F-0011-000
Date :

PC-ME-F-0011-000