Fillable Chesterfield County Environmental Engineering Operation and Maintenance Inspection (Chesterfield County, VA)

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Chesterfield County Environmental Engineering Operation and Maintenance Inspection (Chesterfield County, VA)

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The Chesterfield County Environmental Engineering Operation and Maintenance Inspection (Chesterfield County, VA) form is 2 pages long and contains:

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  • 29 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Chesterfield County, VA

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Chesterfield County Environmental Engineering
Operation and Maintenance Inspection Record
(Underground Pipes, Infiltration Dry Well, Sand Filter, Rain Tank
Storm Filters & Permeable Pavement)
1. A licensed professional engineer or certified inspector must conduct all inspections utilizing the approved
construction plans.
2. As a minimum, all items must be inspected, and note any discrepancies or necessary repairs needed. Include
estimated cost of necessary repairs or actions.
3. Upon completion of the inspection, indicating estimated completion date and cost of noted discrepancies and
repairs, it is to be forwarded by the inspection firm to: Chesterfield County, Department of Environmental
Engineering, Attn: BMP Section, P.O. Box 40 Chesterfield, VA 23832. The original form must be forwarded to
the owner of the facility for signature by the organization's representative.
4. The facility owner's representative must indicate on his/her photocopy the actual completion date and actual cost
of acquired repairs and return the form to: Chesterfield County, Department of Environmental Engineering Attn:
BMP Section, P.O. Box 40 Chesterfield, VA 23832
Project Name:
Facility ID:
Facility Address:
Inspection Date:
Facility Owner:
Facility Type:
Inspection Item
YES NO N/A If YES Describe Required Repairs
Estimated Cost
Of Repairs
VAULT
Cracks, depressions, erosion, sinkholes
or seepage present?
Obstructions (debris, trash) present?
Sediment build up present?
Outlet (clogged, orifice plate missing)?
OTHER
Access - overgrown, missing/broken
grates/manhole covers
Media - clogged, contaminated, needs
replacing?
Observation wells - not capped, trash,
debris, overgrown, broken?
Underdrains - blockage, standing water,
broken?
Other (Pump working, roof area clean,
gutters clean) (if applicable)?
NOTES/COMMENTS (Attach supplemental paperwork if necessary):
Page 1 of 2
OPERATION AND MAINTENANCE INSPECTION RECORD
Page 2 of 2
Project Name:
Was maintenance completed? Y/N
Estimated repair
c
completion date:
Total estimated
c
cost of repairs:
PROFESSIONAL ENGINEER'S INFORMATION
Inspection conducted by:
P.E.
Email: _____________________________________________________________
Address (Street, City, St., Zip):
Phone:
Firm:
Signature of P.E
Inspection conducted by:___________________________________________________________________________________________________________________
Email: _________________________________________________________________________________________
Address (Street, City, St., Zip): __________________________________________________________________________________________________________________
_________________________________________________________________________________
Phone:
Company Name: ________________________________________________________________________________
Signature of SWIN:
FACILITY OWNER /OWNER'S REPRESENTATIVE INFORMATION
In
Owner/Representative Name::_________________________________________________________________________________________________________________
Title: _________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________________________________________
_________________________________________________________________________________
Phone:
Email: _______________________________________________________________________________
Owner/Representative 's Sign
STORMWATER INSPECTOR INFORMATION
Place professional stamp here and date
SWIN#:
____________________________
_
Date all repairs were
completed
Total cost of all repairs
I hereby confirm all information on this form is accurate. Having consulted the plans, and completed maintenance, the facility addressed
will function as designed
.
Owner/Representative 's Signature: _______________________________________________________________________________
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Chesterfield County Environmental Engineering Operation and Maintenance Inspection (Chesterfield County, VA)

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Completed 2 August 2020

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