Leak Report and Customer Damage Report Form

Leak Report and Customer Damage Report Form

This form is to be completed by the responding technician for any WO with a leak, fire/smoke, or other type of property damage. This form is also completed anytime a customer claims that there is property damage caused by Quench employees, equipment, or installation components.
Date*

MonthDayYear
Technician Name*
Field Service Manager (FSM): *
RSD*
Customers Address*

Company Name

Street Address

CityState / Province

Postal / Zip CodeCountry
Contact Name*

First NameLast Name
Contact E-mail
Contact Phone Number*

Area CodePhone NumberExt
Technician Response

MonthDayYear
Date WO Opened

MonthDayYear
SMAX WO#*
Quench Unit Type*
Q #*
Scan Q # Barcode
MFG Serial #
Scan Serial Barcode
Building Floor
Where is the unit located inside the building
Type of Install

CopperPlastic
If Plastic, fill out type

Black TubingWhite TubingOther
Did Customer arrange professional cleaning/remediation services prior to Quench arrival?

YesNo
Photos Taken?

YesNo
Upload Photo

Upload a File
- Wide shot of location of leak including: All other equipment that could contribute to damage (refrigerators, ice machines, coffee makers, sinks, etc.) - Damages caused by leak (multiple photos of all damage) - Origin of leak (multiple pictures) - Picture of part that leaked (any serial numbers or parts number markings) - Picture of pressure reducer (if there is one) - Q number of unit - Manufacturer serial number and model number Cancelof
Pressure Regulator Installed

YesNo
Incoming water pressure (psi)?
Is a leak detector installed (either inside or external to unit)?
Is a leak detector installed (either inside or external to unit)?

YesNo
If yes, was the leak detector functioning properly? If not, why not? (i.e. if it was pill type detector, where the pills present or was the leak detector disabled?)
Picture of the leak detector if one is installed
Potential Origin of Leak (give description)
Damage caused by leak (give description)
- Specify what items were damaged (such as cabinets, floor, carpet, drywall, ceiling tiles, etc.) - Specify how large of an area was affected by the damage (one room, multiple rooms, a hallway, the floor below, the suite next door, etc.) - Specify if it was just our customers site that was damaged, or other sites as well (such as the suite next door, the suite downstairs, or a shared hallway)
Customers Name*
Technicians Signature*

Clear
E-mail
Should be Empty: