Leak(s) Customer Diagnostic Survey Form
Customer Name *
Date *
MM
/
DD
/
YYYY
License Plate #
VIN
Define the concern
Clear selection
Type of Colour of leak(s)
If other, please explain
Location of leak(s)
Description of leak location
Concern is Occurring...
Clear selection
When does the concern occur?
Vehicle speed (km/hr)
Engine speed (RPM)
Engine temp
Clear selection
What accessories are on when leak occurs?
Does any action stop / change the leak?
When did the leak start?
MM
/
DD
/
YYYY
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