Maintenance Inspection

• Site conducted

  Select

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

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• Yes

  No

  N/A

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• Yes

  No

  N/A

Maintenance Inspection Information

• Maintenance Inspection Date

  Date

• Customer

• Property Address (Tenant)

• Technician of Record

• Maintenance Inspection Visit No.

• Customer Purchase No. (if applicable)

HVAC Equipment Inspected on this Maintenance Visit

• Rooftop Units Inspected

  Yes

  No

  N/A

• Add media

  Media

• A/C Split Systems Inspected

  Yes

  No

  N/A

• Add media

  Media

• Exhaust Fans Inspected

  Yes

  No

  N/A

• Add media

  Media

• Unit Heaters Inspected

  Yes

  No

  N/A

• Add media

  Media

• Other Equipment Inspected (quantify/note type)

• Add media

  Media

Rooftop Units/Make-Up Air Units/Split Systems

• Replaced Filter(s) as per Agreement

  Yes

  No

  N/A

• Inspect/Test Equipment Electrical Disconnect(s)

  Yes

  No

  N/A

• Visual Inspection of Equipment Housing for Damage

  Yes

  No

  N/A

• Visual Inspection of Burner Section(s)

  Yes

  No

  N/A

• Visual Inspection of Heat Exchanger(s)

  Yes

  No

  N/A

• Visual Inspection of Condenser Coil(s)<br>(comment on damage/cleanliness)

  Yes

  No

  N/A

• Check Compressor(s) and Component(s)

  Yes

  No

  N/A

• Check Condenser Fans and Blades

  Yes

  No

  N/A

• Check Voltage and Amperage Draws on Motors

  Yes

  No

  N/A

• Inspect Economizer Section Operation/Settings

  Yes

  No

  N/A

• Check Controls/Thermostat Operation

  Yes

  No

  N/A

• Check/Adjust Belts/Pulleys

  Yes

  No

  N/A

• Lubricate Motors/Bearings

  Yes

  No

  N/A

• Check Drain Pans and P-Traps

  Yes

  No

  N/A

• Inspect Gas Line Piping to Unit<br>(Comment on Pipe Painting/Supports)

  Yes

  No

  N/A

Exhaust Fans

• Visual Inspection of Exhaust Fan Housing

  Yes

  No

  N/A

• Inspect Exhaust Fan Electrical Disconnect(s)

  Yes

  No

  N/A

• Check and Adjust/Replace Exhaust Fan Belts/Pulleys

  Yes

  No

  N/A

• Inspect/Check Exhaust Fan Drive Shafts

  Yes

  No

  N/A

• Inspect/Check Exhaust Fan Motors (Amperage/Voltage)

  Yes

  No

  N/A

• Lubricate Exhaust Fan Motors/Bearings

  Yes

  No

  N/A

Radiant Heaters/Unit Heaters

• Check Radiant/Unit Heater Supports & Housing

  Yes

  No

  N/A

• Visual Inspection of Radiant/Unit Heater Burner(s)

  Yes

  No

  N/A

• Visual Inspection of Heat Exchanger (Comment on Condition)

  Yes

  No

  N/A

• Visual Inspection of Radiant Heater Tubing

  Yes

  No

  N/A

• Check/Inspect Venting and Air Intakes

  Yes

  No

  N/A

• Check/Inspect Gas Lines and Valves

  Yes

  No

  N/A

• Test/Check Unit/Radiant Heater Thermostat(s)

  Yes

  No

  N/A

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• Preventative Maintenance Comments/Recommendations

• I have acknowledged that the work as outlined herein have been preformed and are satisfactory. It is agreed that Fiscom Air Systems Inc. will retain title of any equipment and/or materials that have been furnished during the maintenance visit until final payment has been made. If payment is not made as stated herein, Fiscom Air Systems Inc. shall have the right to remove same and will not be held responsible for any loss/damage resulting form the removal thereof.

• Authorized Signature:

  Sign

• Maintenance Inspection Report emailed to:

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• MAINTENANCE CHARGE

• H.S.T. (#867536120R)

• TOTAL CHARGE

• PAYMENT TERMS: Net 30 days. Two Percent (2%) interest per month charged on overdue accounts. Any dispute regarding this work or invoice must be made within ten (10) days from the invoice date, in writing.