Title Page
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Conducted on
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Prepared by
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Branch
HVAC
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Is the branch on Smart Building
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HVAC #1 Equipment Location
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Notes
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Equipment Service area
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Notes
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HVAC Manufacturer
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HVAC Model #
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Date Maufacturered
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Notes
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AC Condenser Unit
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Location
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Condenser coils cleaned
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Notes
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Filter Size
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Filter Changed
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Belt Size/Part #
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Belt Changed
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Wall thermostat Manufacturer
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Model#
HVAC #2
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HVAC #2 Equipment Location
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Notes
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Equipment Service area
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Notes
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HVAC Manufacturer
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HVAC Model #
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Date Maufacturered
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Notes
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AC Condenser Unit
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Location
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Condenser coils cleaned
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Notes
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Filter Size
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Filter Changed
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Belt Size/Part #
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Belt Changed
HVAC #3
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HVAC #3 Equipment Location
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Notes
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Equipment Service area
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Notes
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HVAC Manufacturer
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HVAC Model #
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Date Maufacturered
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Notes
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AC Condenser Unit
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Location
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Condenser coils cleaned
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Notes
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Filter Size
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Filter Changed
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Belt Size/Part #
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Belt Changed
HVAC #4
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HVAC #4 Equipment Location
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Notes
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Equipment Service area
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Notes
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HVAC Manufacturer
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HVAC Model #
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Date Maufacturered
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Notes
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AC Condenser Unit
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Location
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Condenser coils cleaned
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Notes
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Filter Size
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Filter Changed
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Belt Size/Part #
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Belt Changed
Wash Bay Heater, Unit #1
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Type of heater, Unit #1
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Notes
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Gas or Electric
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Notes
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Unit #1 location
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Manufacturer
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Model #
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Notes
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Unit #1 Overall Condition
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Notes
Wash Bay Heater, Unit #2
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Type of heater, Unit #2
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Notes
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Gas or Electric
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Notes
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Unit #2 location
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Manufacturer
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Model #
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Notes
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Unit #2 Overall Condition
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Notes
Wash Bay Heater, Unit #3
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Type of heater, Unit #3
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Notes
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Gas or Electric
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Notes
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Unit #3 location
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Manufacturer
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Model #
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Notes
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Unit #3 Overall Condition
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Notes
Wash Bay Heater, Unit #4
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Type of heater, Unit #4
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Notes
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Gas or Electric
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Notes
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Unit #4 location
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Manufacturer
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Model #
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Notes
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Unit #4 Overall Condition
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Notes
Phone System
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Manufacturer
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Notes
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Model #
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Does the phone system have a back up battery power supply? Most would be APC brand.
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Manufacturer and Model #
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Notes
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System Location
Camera System
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Does the branch have a security camera system in place?
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Manufacturer
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Model #
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Service Provider/Installer
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Notes
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DVR/monitor location
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User name
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Password
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System is in good working condition? All cameras provide a clear view and picture on the monitor.
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What is wrong with the camera system? What follow up is needed?
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Camera #1
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Interior or Exterior?
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Placement/location
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Camera #2
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Interior or Exterior?
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Placement/location
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Camera #3
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Interior or Exterior?
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Placement/location
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Camera #4
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Interior or Exterior?
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Placement/location
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Camera #5
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Interior or Exterior?
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Placement/location
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Camera #6
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Interior or Exterior?
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Placement/location
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Camera #7
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Interior or Exterior?
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Placement/location
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Camera #8
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Interior or Exterior?
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Placement/location
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Camera #9
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Interior or Exterior?
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Placement/location
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Camera #10
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Interior or Exterior?
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Placement/location
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Camera #11
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Interior or Exterior?
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Placement/location
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Camera #12
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Interior or Exterior?
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Placement/location
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Camera #13
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Interior or Exterior?
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Placement/location
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Camera #14
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Interior or Exterior?
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Placement/location
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Camera #15
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Interior or Exterior?
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Placement/location
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Camera #16
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Interior or Exterior?
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Placement/location
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Safes
Floor Safe #1
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Location
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Manufacturer
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Model #
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Battery type
- 9 volt
- AA
- AAA
- D
- C
- Other
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Quantity of batteries
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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How to access the battery(ies)
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Notes
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Battery(ies) replaced
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Notes
Floor Safe #2
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Location
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Manufacturer
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Model #
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Battery type
- 9 volt
- AA
- AAA
- D
- C
- Other
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Quantity of batteries
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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How to access the battery(ies)
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Notes
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Battery(ies) replaced?
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Notes
Wall Safe #1
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Location
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Manufacturer
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Model #
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Battery type
- 9 volt
- AA
- AAA
- D
- C
- Other
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Quantity of batteries
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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How to access the battery(ies)
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Notes
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Battery(ies) replaced?
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Notes
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Does the branch have the back-up key (circular, barrel shaped key) to access the wall safe if the batteries die?
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What is the key cylinder code? Locate the cylinder by removing the small plastic cover (some have the brand name on the cover)
Wall Safe #2
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Location
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Manufacturer
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Model #
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Battery type
- 9 volt
- AA
- AAA
- D
- C
- Other
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Quantity of batteries
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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How to access the battery(ies)
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Notes
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Battery(ies) replaced?
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Notes
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Does the branch have the back-up key (circular, barrel shaped key) to access the wall safe if the batteries die?
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What is the key cylinder code? Locate the cylinder by removing the small plastic cover (some have the brand name on the cover)
EPLEX door locks
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Batteries replaced
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How many EPLEX door locks are onsite?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Are they in good working order?
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Notes
Door lock Cylinder Preventative Maintenance
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All lock cylinders lubricated with Tri-Flow? (doors, pad locks, etc)
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What follow up is needed to PM each cylinder?
Fire Extinguishers & Emergency Lighting
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All Fire Extinguishers ANNUAL inspection completed January 2019? (The tag will be punched on the month and year)
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What date was their last ANNUAL inspection?
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Is Cintas the service provider on the inspection tag?
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Who is the provider?
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Are they compliant? Good working order, charge gauge in the green, pin intact, no damage
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What follow up must be completed?
- Damaged
- Pin missing
- Discharged
- Charge gauge outside for the green
- missing
- other
- Missing annual inspection tag
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Notes
Location of each fire extinguisher
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Location #1
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #2
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #3
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #4
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #5
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #6
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #7
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #8
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #9
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #10
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #11
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #12
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #13
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #14
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
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Location #15
- Main Lobby
- Vestibule
- Hall way
- Branch managers office
- Mechanical/Network room
- Break room
- Back hallway
- Wash bay
- Storage Room
- Other
Emergency Lighting
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Tested each unit for good working order
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What follow up is needed?
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Location of unit(s) needing repair
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Service provider (most will be Cintas)
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Provider name
Location of each Emergency Light/Exit sign
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Location #1
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Location #2
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Location #3
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Location #4
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Location #5
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Location #6
Eye Wash Station
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Eye wash station onsite in the wash bay?
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Manufacturer
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Model #
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Are they in good working order to provide 15 minutes of consistent water? (Test for 30 seconds)
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What follow up is needed?
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Location (if more than one eye wash station is onsite)
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Wall sign is visible and in good condition?
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What follow up is needed?
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Location (if more than one eye wash station is onsite)
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Wall bracket in good condition? If rusted = fail
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Dust caps in good condition?
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No active leaks?
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Notes/Comments
Water Quality
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Water Softner
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Manufacturer
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Model #
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Gallons
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Date installed or manufactured
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Water softner salt needed?
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Notes
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Hot Water Heater
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Manufacturer
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Model #
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Gallons
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Date installed or manufactured
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Does hot water run from the sink?
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Is the pilot light out? Are the electric heater elements out?
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Follow up needed
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Notes
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Does the hot water feel scolding hot?
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Lower the temp
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What follow up is needed?
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Anode rode need replacement?
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Notes
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Hot water heater flushed out
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What follow up is needed to flush it out?
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Water quality?
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Does it smell like iron? rust color to the water? Toilet stained orange from the iron
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Are the faucet aerator in good working order? Not caked up with mineral deposits? Water flow is sufficient?
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Location of failed aerator
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Size/thread needed
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If on well water do they have a pressure tank
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Condition of pressure tank?
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Service provider sticker on pressure tank?
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Do they have an iron filter?
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Condition of iron filter?
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Service provider sticker on iron filter?
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Notes
Carpet and Paint
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Carpet in good condition
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Measure out the whole office or area where replacement is needed
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Take a photo of your drawing with measurements
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Paint in good condition (Interior)
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What accent wall color is needed
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Notes
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Door and window jambs/sills/moldings in good condition?
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What needs to be painted our tradedress black?
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Paint in good condition (Exterior)
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Do we have our tradedress, moderate white on the exterior?
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Notes
Restroom
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Flooring in good condition
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Tradedress ceramic tile
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If ceramic tile is needed, measure the space for floor and a 4' tall boarder on the walls
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Take a photo of your drawing with measurements
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Walls in good condition
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What follow up is needed?
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Fixtures look current and not tired/old/rusted out
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Take photos of current fixtures