Email Address:

Subject (Site Name):

Work Order Number:

Inspector: Date:

Site Name, City, County:

Location of installed receiver:

Contact Name and Number

Station Frequency: Serial Number/Version

Antenna Type:

Programmed Number Version

Fee: $ Feet of Cable: Ant. Other:

Miles:

Signal Test: 0 blinks/min 1-5 blinks/min 6 or more/min

Last Daily Test? Past 5 Days?

Person Alert Test Notes:
Alert Received? please choose Yes No

Shown Website? please choose Yes No

Battery OK? please choose Yes No

Station Audio Clear? please choose Yes No

Additional Notes: