Get DA Form 5457 2005-2024

REPORT DATE POTABLE WATER CONTAINER INSPECTION For use of this form see TB MED 577 the proponent of this form is the Office of The Surgeon General. TO FROM INSPECTION RATING SERIAL NUMBER MAP COORDINATE LOCATION OWNING UNIT MAINTENANCE NCO UNIT REPRESENTATIVE INSPECTION UNIT DATE/TIME GROUP INSPECTED BY SECTION I. WATER TRAILER INSPECTION CRITERIA YES 1. CONTAINER EXTERIOR a. Marked POTABLE WATER ONLY b. Clean/Good Repair 2. REPORT DATE POTABLE WATER CONTAINER INSPECTION For use of this form see TB MED 577 the proponent of this form is the Office of The Surgeon General* TO FROM INSPECTION RATING SERIAL NUMBER MAP COORDINATE LOCATION OWNING UNIT MAINTENANCE NCO UNIT REPRESENTATIVE INSPECTION UNIT DATE/TIME GROUP INSPECTED BY SECTION I. WATER TRAILER INSPECTION CRITERIA YES 1. CONTAINER EXTERIOR a* Marked POTABLE WATER ONLY b. Clean/Good Repair 2. MANHOLE COVERS a* b. c* d. Rubber Gasket Intact Locking Mechanism Functions No Rust/Insulation Intact Pressure Relief Valve Operates 3. DISPENSING SPIGOTS All Spigots Function T Handle Operates Easily Protective Box Intact Locking Devices Function 4. DRAIN Plug Installed Hand-Tight Cracks Do Not Expose Fiberglass Plug/Hole Threads Undamaged Threads Not Rusted 5. CONTAINER INTERIOR STAINLESS STEEL AND ALUMINUM NO No Rust Not Painted/Coated No Cracks/Dents Exposing Polyurethane FIBERGLASS Cracks/Chips Less Than 10 Fiberglass Exposed Paint Surface Not Flaking PORTS 3. DISPENSING VALVES a* Valves Operate Easily b. Hose Coupling Threads Undamaged c* Dust Caps Attached to Valve Ports 4. TANK INTERIOR c* Steel/Aluminum Not Painted DA FORM 5457 NOV 2005 APD LC v1. 01ES SECTION III. FABRIC TANK/DRUM INSPECTION CRITERIA c* Plugs/Patches Secure 2. VALVE ASSEMBLY a* Check-Valve Adapter Undamaged b. Coupler Valve Operates Easily SECTION IV. CONTAINER LOCATION FIELD USE INSPECTION CRITERIA 1. SITE CONDITIONS a* Manholes/Parts Closed b. Soakage Pits Constructed Beneath Spigots 2. WATER CONDITIONS a* Chlorine Residual Adequate b. Procured From ppm COMMENTS AND RECOMMENDATIONS PRINTED/TYPED NAME AND GRADE OF PVNTMED INSPECTOR SIGNATURE REVERSE OF DA FORM 5457 NOV 2005. WATER TRAILER INSPECTION CRITERIA YES 1. CONTAINER EXTERIOR a* Marked POTABLE WATER ONLY b. Clean/Good Repair 2. MANHOLE COVERS a* b. c* d. Rubber Gasket Intact Locking Mechanism Functions No Rust/Insulation Intact Pressure Relief Valve Operates 3. MANHOLE COVERS a* b. c* d. Rubber Gasket Intact Locking Mechanism Functions No Rust/Insulation Intact Pressure Relief Valve Operates 3. DISPENSING SPIGOTS All Spigots Function T Handle Operates Easily Protective Box Intact Locking Devices Function 4. DISPENSING SPIGOTS All Spigots Function T Handle Operates Easily Protective Box Intact Locking Devices Function 4. DRAIN Plug Installed Hand-Tight Cracks Do Not Expose Fiberglass Plug/Hole Threads Undamaged Threads Not Rusted 5. DRAIN Plug Installed Hand-Tight Cracks Do Not Expose Fiberglass Plug/Hole Threads Undamaged Threads Not Rusted 5. CONTAINER INTERIOR STAINLESS STEEL AND ALUMINUM NO No Rust Not Painted/Coated No Cracks/Dents Exposing Polyurethane FIBERGLASS Cracks/Chips Less Than 10 Fiberglass Exposed Paint Surface Not Flaking PORTS 3.