Leak Report Form
To be completed by Responding Technician
Date
*
-
Month
-
Day
Year
Date Picker Icon
Technician Name
*
Field Service Manager (FSM):
*
Select One
Alicia Jones
Percy Allen
Anthony Pomes
Anthony Quezada
Robert W. Campey
Jose G. Collado
Nathaniel Cox
Dale Hanks
Lamontae Daley
Danial Silvestre
Daren Killingsworth
Daryl Linville
Estefan Jimenez
Robert Demontigny
Russell Fawcett
Joseph Hickman
James Johnson
Jason Healy
Jim Baumgartner
Jon Burnham
Jose Marte
Julio Curiel
Keith Lloyd
Troy Lafferty
Oscar Lamm
Adolf Lederer
Jason Lee
Jordon Lill
Christopher Link
Brent Luedtik
Carmelo Manessis
Mario Mendez
Jozef Matilszki
Matt Craig
Jason Miller
Charles Murphy
Open - Los Angeles
Open - Salt Lake City
David Perez
Jerry Phillips
Gary Ray
Robert Reichow
Rhea-Ann Hamzy-McMeans
Rudy Gonzales
Randy Saifur
Scott Meagher
Sean Dunaway
Sean Selliken
Steve Hlwiski
Steve Weisenberger
Kenneth Taylor
Cary Thomas
Austin Thompson
Waldy Negron
Customers Address
*
Company Name
Street Address
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Contact Name
*
First Name
Last Name
Contact E-mail
Contact Phone Number
*
Area Code
Phone Number
Ext
Technician Response
-
Month
-
Day
Year
Date Picker Icon
Date WO Opened
-
Month
-
Day
Year
Date Picker Icon
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
Copper
Plastic
If Plastic, fill out type
Black Tubing
White Tubing
Other
Did Customer arrange professional cleaning/remediation services prior to Quench arrival?
Yes
No
Photos Taken?
Yes
No
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
Cancel
of
Pressure Regulator Installed
Yes
No
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)?
Yes
No
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
Submit to Manager
Should be Empty: