Fillable Form 376 Filterra® Device Operation And Maintenance Inspection Report (Chesterfield County, VA)

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Form 376 Filterra® Device Operation And Maintenance Inspection Report (Chesterfield County, VA)

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The Form 376 Filterra® Device Operation And Maintenance Inspection Report (Chesterfield County, VA) form is 2 pages long and contains:

  • 2 signatures
  • 48 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

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

BROWSE CHESTERFIELD COUNTY, VA (VA) FORMS

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Form # CEE
CHESTERFIELD COUNTY
DEPARTMENT OF ENVIRONMENTAL ENGINEERING
OPERATION AND MAINTENANCE INSPECTION AND REPAIR RECORD
FILTERRA®
1. A licensed Professional Engineer or certified Filterra® Inspection Specialist must conduct all inspections utilizing the
approved construction plans.
2. As a minimum, all items must be inspected, with any discrepancies or necessary repairs noted.
3. Upon completion of the inspection, one copy of this report with the estimated completion date and cost of noted
discrepancies and repairs 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.
4. The facility owner's representative must indicate on his/her copy the actual completion date and actual cost of required
repairs and return the form to: Chesterfield County, Department of Environmental Engineering, Attn: BMP Section,
P. O. Box 40, Chesterfield, VA 23832.
5. This form is to be used for Filterra® devices and requires inspections and maintenance every six months.
Project Name:
Facility ID:
Facility Location:
Inspection Date:
Facility Owner:
Facility Type:
Inspection Item
Describe Repairs Performed/Required
Initial Observation
Standing Water?
Yes
No
Damage to Box Structure?
Yes
No
Damage to Grate?
Yes
No
Is Bypass Clear?
Yes
No
Waste
Silt/Clay
Yes
No
Cups/Bags/Trash
Yes
No
Leaves
Yes
No
Other
Yes
No
Media
Thickness of Media (in.)
in.
Media Type:
Mulch
Netting Replaced?
Yes
No
Mulch Replaced or
Added?
Yes
No
Stones Replaced?
Yes
No
Type of Mulch
Added or Replaced?
Plantings
Plant Information
#1
#2
#3
#4
#1
#2
#3
#4
Height Above Grate? (ft. in.)
Health of Plant (s)
Alive/Dead
Alive/Dead
Alive/Dead
Alive/Dead
Stem Diameter/Caliper? (in.)
Damage to Plant?
YES / NO
YES / NO
YES / NO
YES / NO
Width at widest Point? (ft. in.)
Plant Replaced?
YES / NO
YES / NO
YES / NO
YES / NO
For Internal Use Only
Silt/Clay
Yes
No
Cups/Bags/Trash
Yes
V No
Leaves
Yes
No
Other
Yes
No
Page 1 of 2
Form # CEE
Filterra® Specialist Information:
Filterra® Specialist Name: ___________________________________________________________________ Certification #: __________________________________
Phone Number: _____________________________________________________________________________________________________________________________________
Email: ________________________________________________________________________________________________________________________________________________
Company Name: ____________________________________________________________________________________________________________________________________
Address (Street, City/St./zip):_____________________________________________________________________________________________________________________
Filterra
® Specialist Signature: ____________________________________________________________________________________________________________________
Professional Engineer's Information:
Inspection Conducted By: _____________________________________________________________________
P. E.
Phone Number: ____________________________________________________________________________________
Email: _______________________________________________________________________________________________
Firm: ________________________________________________________________________________________________
Address (Street, City/St./zip):____________________________________________________________________
_______________________________________________________________________________________________________
Signature of P.E
Performing Inspection:
Place Professional Stamp Here and Date
Facility Owner Information:
Owner/Representative Name: ______________________________________________________________________
Representative's Title: _______________________________________________________________________________
Mailing Address: ______________________________________________________________________________________
__________________________________________________________________________________________________________
Phone Number: ________________________________________________________________________________________
_
E-Mail Address: _________________________________________________________________________________________
The Filterra
® BMP's on my property have been maintained per Filterra's® Maintenance Specifications.
Owner/Representative 's Signature
Actual Date All Repairs Completed
Actual Total Cost of Repairs
Page 2 of 2
Was maintenance completed? Y/N
Estimated repair
c
completion date:
Total estimated
c
cost of repairs:
007
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Form 376 Filterra Device Operation And Maintenance Inspection Report (Chesterfield County, VA)

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Completed 15 July 2020

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