Utilities Form

Free Fillable Cathodic Protection Survey

Fill out this cathodic protection survey online and download as PDF - free, no signup required.

UP-0229 fieldssurvey

Project Information

Project Name*

Test Station ID*

Technician Name*

Survey Date*

Pipeline Operator

Line Designation

Milepost / Station

Reference Electrode Type

Pipe-to-Soil Potential Readings

P/S On Potential (mV)

Structure potential with current applied (mV vs CSE)

P/S Off Potential (mV)

Instant-off potential (mV vs CSE)

Protection Criterion Met*

DC Current Flow (mA)

Casing/Pipe Potential (mV)

If applicable — casing vs carrier pipe

Soil Resistivity (ohm-cm)

Rectifier Inspection

Rectifier at This StationRectifier at This Station

Anode Condition

Anode Type

Anode Current Output (mA)

Anode Condition

Anode Replacement RequiredAnode Replacement Required

Test Station Location

Test Station Box Condition

Wire / Lead Condition

CP Notes

Photos

Location

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Pipeline Patrol

UP-01