Call Taken By / Date Employee First Received Call
Assignment Given To / Time Employee First Received Call
CONTACT INFORMATION
Contact Name / Address / City / Zip
X-Street / Lateral LocationU/S / Lateral LocationD/S / Ph. Work
Property Type* / Owner/Tenant / Problem Code / Home
*Single family dwelling, apartments, commercial
PROPERTY OWNER INFORMATION (if different)
Prop. Owner Name / Address / City / Zip
Comments / Property Owner Ph. Work
Home
FIELD REPORT
Date of Arrival / Time of Arrival / Line Size / Footage
Resolution Code/Comment / Stoppage Location / U/S / — / D/S
Employee No. / Hrs. Worked / OT Hours / Vehicle
Nos. / Hrs.
Used / SR No. Office Use /
Comments / Special Conditions
Reporting Spills InformationNOTE: If there is an SSO you must fill out the SSO Response Field Documentation Form.
Page 1 of 2 Revised Dec-2011
Problem CodeResolution/Action Code
001 / Lateral Stoppage / 001 / Homeowner Problem—Notified Owner / 018 / ACWD—Notified Agency002 / Main Stoppage / 003 / Pump Station / 019 / Made Repair for Contractor
003 / Pump Station / 004 / Storm Inlet / 020 / Temporarily Repaired
004 / Storm Drain Inlet / 005 / Storm Line / 022 / Referred to Others
005 / Storm Line / 006 / Washed-down/Deodorized / 028 / USD Bubbled Toilet/Cleaned Up
006 / Odor (Complete report below) / 007 / Noisy MH/Riser—Silenced / 029 / Odor Homeowner Problem
007 / Noisy MH/Riser Cover / 008 / Broken MH/Riser Replaced / 031 / Foreign Object Removed
008 / Broken, Cracked, or Missing MH/Riser / 009 / Cave In—Area Secured / 035 / Sink Hole Problem Solved
009 / Cave-ins / 010 / Broken Line—Repaired / 066 / Resolved Problem-See Comments
010 / Broken Line / 011 / City of Fremont—Notified Agency / 350 / Replace Stolen MH Cover
011 / Refer to Others / 012 / City of Newark—Notified Agency / 500 / Relieve Stoppage – No Spill
012 / Overflowing MH/Riser / 013 / City of Union City—Notified Agency / 501 / Relieve Stoppage – Minor 1000
013 / Overflowing Cleanout / 014 / PG&E—Notified Agency / 502 / Relieve Stoppage – Major > 1000
014 / Overflowing MH Private / 015 / Pac Bell-Notified agency / 503 / Relieve Stoppage – Private Spill
030 / Stoppage/Overflow / 016 / ACFC-Notified Agency / 504 / Cleaned Minor Spill < 1000
031 / Toilet Bubbled Over After USD Cleaned Line / 017 / Caltrans-Notified Agency / 505 / Cleaned Major Spill > 1000
035 / Sink Hole / 506 / Cleaned Private Spill
ODOR COMPLAINT DATA FOR BOARD REPORTING
(Please fill out this section completely with clear explanations)
IF ODOR IS POSSIBLY RELATED TO THE “PLANT” OR REPORTING PARTY SAYS IT IS “DUE TO THE PLANT”,
LET PLANT TPO COACH KNOW
Day / Date / Time / Wind (from) / Weather / TempWind (speed)
Contact / Location / Complaint
Bus. Name / City, St
Phone (H) / Zip (Must Have)
Phone (W) / X-Street
1.What you inspected
(main, storm D/I, water channel...) / 3.Action you took / 5.Information you gave to complainant
2.What you found
(describe odor, circumstances) / 4. Who you contacted / 6. Recommended follow-up action
Page 2 of 2 Revised Dec-2011
CWEA provides no warranty, expressed or implied, nor assumes any legal liability or responsibility for the accuracy, reliability or completeness of furnished information. While it is our intention to provide training to help you and your agency comply with the SSO WDR, CWEA provides no warranty, expressed or implied, that attending this training and/or using the reference guide and/or database simulation will result in your agency's successful compliance with the SSO WDR. The information provided is not intended to take the place of either the written law or regulations.
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