Authorization Form

Service Order / Receipt
Name

First NameLast Name
Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
Service address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred by:
Phone Number

Area CodePhone Number
Insurance Co.
Claim No
Insurance Co. email:
Invoice paid by
Service Requested

Leak Detection / Service Call / Consultation $Weekend – After Hours / Travel $Amount Paid: Check # Credit Card Cash $
Service Description:
An electronic / acoustic, meter test and static pressure test were utilized to determine that no leaks were present in the
pressurized domestic water system at the time of the survey. Water system was holding pressure of
blanks field. PSI for blank.
I hereby acknowledge that “Mr.Leak Detector” informed me that I should have a hazardous material survey (including but not limited to the testing for asbestos, lead and mold) prior to having anyone perform any invasive actions to the ceilings, walls, floors and other building materials.

I have declined “Mr.Leak Detector” recommendation to have a hazardous material survey completed and requested that they continue with their work without delay.

I clearly understand that their investigation may involve disturbing the ceilings, walls, floors and other building materials in order to
attempt to locate the plumbing leak.

I am hereby releasing “Mr.Leak Detector” from any and all liability and/or any responsibility for any contamination of hazardous materials (including but not limited to asbestos, lead and mold) whether caused by “Mr.Leak Detector” or any others that results from my decision not to have a hazardous material survey completed.

I authorize “Mr.Leak Detector” to perform the services requested as specified in the Customer Authorization Agreement on the reverse side, and approve the statement above:
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Service Order / Receipt