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