Company Name: Inspector Name: Address: Contact Phone: address (print) Inspector Pipeline Assessment Certification (PACP) NASSCO #:

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1 Proerty Information: Building Sanitary Sewer Insection Form 1A Sanitary Sewer Overflows This form must be comleted and signed by a licensed contractor who is on the City of Santa Cruz Public Works Deartment list of Certified Sewer Insectors and submitted to: City of Santa Cruz Public Works Deartment Santa Cruz, CA Proerty Address: Proerty Owner(s) name: Residential, number of units served Commercial City: State: Zi Code: Owner Contact Phone Number: Insector Information: Comany Name: Insector Name: address (rint) Insector Pieline Assessment Certification (PACP) NASSCO #: Insection: Date of Insection: / / Pie Size: Pie Material: CCTV Date: / / Time: Camera Direction: With Flow Against Flow Length: Cause of Overflow: Roots Grease Other Yes No There is a standard clean-out in the sidewalk area Yes No (If NO to above) clean-out is accessible outside of building Yes No There is a sewer lift station (um) at this roerty Yes No Proerty has been verified as not requiring a backwater valve Yes No Proerty has been verified as having a working backwater valve Yes No Proerty needs a backwater valve Yes No Proerty has been verified as having no outside drains or sum ums connected to the building sanitary sewer. Cause of Overflow: Yes No Roots, Correction Made: Yes No Faulty Clean Out, Correction Made: Yes No Offset Joint, Correction Made: Yes No Grease, Correction Made: Yes No Structural, Correction Made: Other (not listed): Please give your rofessional oinion on the condition of the building sanitary sewer or sanitary sewer collection system: NOTE: 1. No Building Sanitary Sewer shall have a grade (4) or grade (5) structural condition. 2. No Building Sanitary Sewer shall have a grade (3) oerational condition. (When the insection camera is submerged at any time during video insection then the sewer is determined to have a grade three (3) oerational Sag.) As the insector for the above-mentioned roerty, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municial Code I certify under enalty of law that the information and video recording I have rovided with this form is true and correct. Signature of Insector: Date:

2 City of Santa Cruz Building Sanitary Sewer Insection Form - Sanitary Sewer Overflows Immediately: if a roerty has a sanitary sewer overflow it shall be considered a nuisance and the roerty owner or homeowner association shall immediately (uon becoming aware) begin taking actions to eliminate the overflow. Evidence of a remedy to be submitted: Within 14 calendar days after the notice of violation is served. All sanitary sewer overflow remedies shall show a building sanitary sewer with no ie structural condition grade 4 or 5 and/or no grade 3 oerational defects. STRUCTURAL OPERATIONAL Structural Defect Grous include: Cracks, breaks, oenings, rodent holes, structural sags or missing ortions. Structural Observation Codes: l Grade 5, Collase or collase imminent. l Grade 4, Collase likely in foreseeable future l Grade 3, Collase unlikely in near future l Grade 2, Minimal collase risk l Grade 1, Accetable structural condition Oerational Defect Grous include: Roots, grease deosits, other solids, which may imede the flow or obstruct the transmission of wastewater. Oerational Observation Codes: l Grade 3, l Grade 2, l Grade 1 l Examle of Structural Grade 5: l Examle of Oerational Grade 3: Severe cracking with offset collase: Major root intrusion: l Examle of Structural Grade 4: l Examle of Oerational Grade 2: Multile structural cracks: Medium root intrusion: l Examle of Structural Grade 3: For City Use Only Date Received: Reviewed by: Multile hairline cracks. Distance: Note: A review of the video file revealed that a relacement of reairs to the building sanitary sewer is NOT necessary. A review of the video file revealed that a reair to the building sanitary sewer is required. A review of the video file revealed that the sewer line is required to be relaced.

3 Proerty Information: Building Sanitary Sewer Insection Form 2B Prior to a transfer of ownershi by sale of any roerty or building. This form must be comleted and signed by a licensed contractor who is on the City of Santa Cruz Public Works Deartment list of Certified Sewer Insectors and submitted to: City of Santa Cruz Public Works Deartment Santa Cruz, CA Proerty Address: Proerty Owner(s) or Reresentative name: Residential Commercial City: State: Zi Code: Owner Contact Phone Number: Insector Information: Comany Name: Insector Name: address (rint) Insector Pieline Assessment Certification (PACP) NASSCO #: Insection: Date of Insection: / / Pie Size: Pie Material: Yes No Insection is for the construction of a new dwelling unit that utilizes existing roerty sewer Yes No There is a standard clean-out in the sidewalk area Yes No (If NO to above) clean-out is accessible outside of building Yes No There is a sewer lift station (um) at this roerty Yes No Insection could NOT be done due to substandard clean-out Yes No Proerty has been verified as not requiring a backwater valve Yes No Proerty has been verified as having a working backwater valve Yes No Proerty needs a backwater valve Yes No Proerty has been verified as having no outside drains or sum ums connected to the sewer system Yes No Proerty has a building sanitary sewer that was constructed within 10 years Yes No Proerty sewer was comletely relaced within 10 years Yes No Proerty sewer has been determined to have a structural grade 5 condition, (insector shall rovide video of sewer to buyer rior to correcting grade 5 condition) CCTV Date: / / Time: Camera Direction: With Flow Against Flow Length: Describe structural grade 5 condition and submit ost DVD, flash drive, or digital video of remedy to the City of Santa Cruz Public Works Deartment: NOTE: 1. No Building Sanitary Sewer shall have a grade (5) structural condition. 2. No Building Sanitary Sewer shall have a grade (3) oerational condition. (When the insection camera is submerged at any time during video insection then the sewer is determined to have a grade three (3) oerational Sag.) As the insector for the above-mentioned roerty, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municial Code I certify that the information and video recording I have rovided with this form is true and correct. Signature of Insector: Date:

4 City of Santa Cruz Building Sanitary Sewer Insection Form Uon Transfer of Title of Real Proerty or Construction of a New Dwelling Unit or New Dwelling Unit Utilizing an Existing Building Sanitary Sewer or Commercial Building All existing residential and commercial roerty building sanitary sewers shall, rior to the transfer of title whenever any roerty is to be transferred to or vested in any other erson or entity, excet for an intersousal transfer as defined in the Revenue and Taxation Code Section 63, shall be insected by a NASSCO PCLP certified insector. STRUCTURAL OPERATIONAL Structural Defect Grous include: Cracks, breaks, oenings, rodent holes, structural sags or missing ortions. Structural Observation Codes: l Grade 5, Collase or collase imminent. l Grade 4, Collase likely in foreseeable future l Grade 3, Collase unlikely in near future l Grade 2, Minimal collase risk l Grade 1, Accetable structural condition Oerational Defect Grous include: Roots, grease deosits, other solids, which may imede the flow or obstruct the transmission of wastewater. Oerational Observation Codes: l Grade 3, Severe root intrusion (50% or more) or Sag in ie: camera is comletely submerged. l Grade 2, Moderate root intrusion (50% or less) or camera is artially submerged. l Grade 1 l Examle of Structural Grade 5: l Examle of Oerational Grade 3: Severe cracking with offset collase: Major root intrusion: l Examle of Structural Grade 4: l Examle of Oerational Grade 2: Multile structural cracks: Medium root intrusion: l Examle of Structural Grade 3: For City Use Only Date Received: Reviewed by: Multile hairline cracks. Distance: Note: A review of the video file revealed that a relacement of reairs to the building sanitary sewer is NOT necessary. A review of the video file revealed that a reair to the building sanitary sewer is required. A review of the video file revealed that the sewer line is required to be relaced.

5 Building Sanitary Sewer Insection Form 3C Cleaning of Collection Systems Be cleaned a minimum of once every two (2) years if the system collects wastewater from ten or more building sanitary sewers or every five years if less than 10 building sanitary sewers. Proerty Information: This form must be comleted and signed by a licensed contractor who is on the City of Santa Cruz Public Works Deartment list of Certified Sewer Insectors and submitted to: City of Santa Cruz Public Works Deartment Santa Cruz, CA Proerty Address: Proerty Owner(s) or Reresentative name: Number of units: City: State: Zi Code: Owner Contact Phone Number: Proerty Manager Phone Number: Address: Date of Construction: Insector Information: Comany Name: Insector Name: address (rint) Insector Pieline Assessment Certification (PACP) NASSCO #: Cleaning: Date of Cleaning: / / Pie Size: Pie Material: Method of Cleaning: Hydro Mechanical Number of Manholes Lineal Feet of cleaning done: Yes No There is a sewer lift station (um) at this roerty Yes No Proerty has been verified as having no outside drains or sum ums connected to the sewer system Yes No Roots visible in the manhole(s) Other Comments: NOTE: 1. No Sanitary Sewer Collection System shall have a grade (5) structural condition. 2. No Sanitary Sewer Collection System shall have a grade (3) oerational condition. (When the insection camera is submerged at any time during video insection then the sewer is determined to have a grade three (3) oerational Sag.) As a contractor for the above-mentioned roerty, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municial Code I certify under enalty of law that the information and video recording I have rovided with this form is true and correct. Signature of Insector: Date:

6 Building Sanitary Sewer Insection Form 4D Insection of Collection Systems Every 10 Years Private sanitary sewer collection systems shall be required to televise the sanitary sewer ies every ten (10) years. Proerty Information: This form must be comleted and signed by a licensed contractor who is on the City of Santa Cruz Public Works Deartment list of Certified Sewer Insectors and submitted to: City of Santa Cruz Public Works Deartment Santa Cruz, CA Proerty Address: Proerty Owner(s) or Reresentative name: Number of units: City: State: Zi Code: Owner Contact Phone Number: Proerty Manager Phone Number: Address: Date of Construction: Insector Information: Comany Name: Insector Name: address (rint) Insector Pieline Assessment Certification (PACP) NASSCO #: Insection: Date of Insection: / / Pie Size: Pie Material: Number of Manholes Lineal Feet of televise done: Yes No There is a sewer lift station (um) at this roerty Yes No Proerty has been verified as having no outside drains or sum ums connected to the sewer system Yes No Roots visible in manhole(s) Yes No Proerty sewer has been determined to have a structural grade 5 condition, (insector shall rovide video of sewer to owner rior to correcting grade 5 condition) Post CCTV Date: / / Time: Camera Direction: With Flow Against Flow Length: Describe structural grade 5 condition and submit POST DVD, flash drive, or color digital video of remedy to the City of Santa Cruz Public Works Deartment: NOTE: 1. No Sanitary Sewer Collection System shall have a grade (5) structural condition. 2. No Sanitary Sewer Collection System shall have a grade (3) oerational condition. (When the insection camera is submerged at any time during video insection then the sewer is determined to have a grade three (3) oerational Sag.) As an insector for the above-mentioned roerty, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municial Code I certify under enalty of law that the information and video recording I have rovided with this form is true and correct. Signature of Contractor: Date:

7 City of Santa Cruz Building Sanitary Sewer Insection Form Maintenance Agreement Form for Sanitary Sewer Collection Systems Private sanitary sewer collection systems that serve five (5) dwelling units or more shall be required to televise those same sanitary sewer ies every ten (10) years. STRUCTURAL OPERATIONAL Structural Defect Grous include: Cracks, breaks, oenings, rodent holes, structural sags or missing ortions. Structural Observation Codes: l Grade 5, Collase or collase imminent. l Grade 4, Collase likely in foreseeable future l Grade 3, Collase unlikely in near future l Grade 2, Minimal collase risk l Grade 1, Accetable structural condition Oerational Defect Grous include: Roots, grease deosits, other solids, which may imede the flow or obstruct the transmission of wastewater. Oerational Observation Codes: l Grade 3, Severe root intrusion (50% or more) or Sag in ie: camera is comletely submerged. l Grade 2, Moderate root intrusion (50% or less) or camera is artially submerged. l Grade 1 l Examle of Structural Grade 5: l Examle of Oerational Grade 3: Severe cracking with offset collase: Major root intrusion: l Examle of Structural Grade 4: l Examle of Oerational Grade 2: Multile structural cracks: Medium root intrusion: l Examle of Structural Grade 3: For City Use Only Date Received: Reviewed by: Multile hairline cracks. Distance: Note: A review of the video file revealed that a relacement of reairs to the building sanitary sewer is NOT necessary. A review of the video file revealed that a reair to the building sanitary sewer is required. A review of the video file revealed that the sewer line is required to be relaced.

8 Building Sanitary Sewer Insection Form 5E Annual Insection of Lift Stations Sanitary Sewer Lift Stations and Ejector Pums from sanitary sewer collection systems with five units or more shall be insected annually and less than five units insected every five years. This form must be comleted and signed by a licensed contractor who is on the City of Santa Cruz Public Works Deartment list of Certified Sewer Insectors and submitted to: City of Santa Cruz Public Works Deartment Santa Cruz, CA Proerty Information: Proerty Address: Proerty Owner(s) or Reresentative name: Residential Commercial City: State: Zi Code: Owner Contact Phone Number: Proerty Manager Phone Number: Address: Date of Construction: Insector Information: Comany Name: Insector Name: address (rint) Insector Pieline Assessment Certification (PACP) NASSCO #: Insection of Sewage Ejector Pums for Single Family Dwellings: Date of Insection: / / Yes No The tank and um is accessible for insection, um relacement, or reairs Yes No There is adequate tank venting Yes No There is no evidence of leaks, exosed wires, unrotected oenings into the tank Yes No There is no evidence of backus or overflows which may show recent failures Yes No The um is oerating roerly, (turn on a nearby lumbing fixture to fill the reservoir tank, observe the um oeration, turning on and off normally) Yes No The sewage ejector system has a working alarm that has been tested and will sound _ uon high water level or um failure Yes No The ejector/grinder- um reservoir or basin is undamaged, (the fiberglass or lastic container is intact, with no cracks, breaks, imroer holes, or other damage) Yes No The lid fits securely, is roer material, and not be leaking Yes No A check valve is roerly installed and functioning on the discharge line Insection of Sewage Lift Station: Date of Insection: / / Yes No All ums are oerating roerly, (run each um for a short time) Yes No Wet well have been cleaned and is free of grease and debris, control floats are clean, iing is in good condition Yes No Floats have been turned on and off and work roerly Yes No High water float and alarm is working roerly Yes No All lift station valves have been exercised and are working roerly (including check valves) Yes No If alicable, run time for each um has been recorded Yes No If alicable, generator has been tested and transfers roerly As a contractor for the above-mentioned roerty, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municial Code In order to ass insection all questions secific to tye of installation must be answered YES and ALL deficiencies must be corrected. I certify under enalty of law that the information and video recording I have rovided with this form is true and correct. Signature of Insector: Date: