Utilities Form

Free Fillable Leak Survey

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

UP-0629 fieldscompliance

Project Information

Project Name*

Survey Route / District ID*

Surveyor Name*

Survey Date*

Pipeline Operator

Regulatory Survey Type

Pipeline Material

Survey From (Street/Location)

Survey To (Street/Location)

Instrument Readings

Survey Method*

Instrument Make & Model

Last Calibration Date

Calibration Gas

Wind Speed (mph)

Temperature (°F)

Ground Condition

Leak Grade & Classification

Record each leak found. Grade per AGA/GPTC standards (Grade 1 = immediate hazard, Grade 2 = scheduled repair, Grade 3 = non-hazardous).

Location & Extent

Total Route Length Surveyed (ft)

Total Leaks Found

Grade 1 Leaks

Grade 2 Leaks

Grade 3 Leaks

Inaccessible Areas / Survey Gaps

Repair Priority & Action

Immediate Action Required (Grade 1 Present)Immediate Action Required (Grade 1 Present)

Repair Priority*

Estimated Repair Date

Work Order Number

Survey Notes

Photos

Location

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DOT Compliance Checklist

UP-05

Coating Inspection

UP-07

Excavation & Damage Prevention

UP-08