Title Page
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Location
Job Details
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Name of Establishment
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Address of Establishment
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Contact Person Name
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Contact Person Phone No.
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Work Order No.
Thermostatic Mixing Valve Details
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Make and Type of Hot Water Unit(s):
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Make of Mixing Valve
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Model No
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Size (mm)
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Total No Of Mixing Valves on Site / Building
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Valve Identification No.
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Location of Valve
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Areas Served by the Valve
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No of Outlets Served but the Valve
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Mixing Valve Installed to the requirements of:
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The Valve manufacturer / supplier
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The Code for Thermostatic Mixing Values
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The Local Water Supply Authority
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If No, give details and action taken
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Advised D.ON / Administration
Thermostatic Valve Inspection - Pariculars of work carried out during this visit
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Inspection Type
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Serviced
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Commissioned
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Dismantle
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Visually inspect and clean valve componenets
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Check function of non return vavles
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Replace O rings and lubricate
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Reassemble
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Set Temperature
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Adults
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Children
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Thermal Shutdown Test Passed
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List of items replaced and part numbers during this visit
Temperature range of water at outlet:
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Neonatal and Children's
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Adult's
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Other
Service schedule details
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Date of this service / commissioning
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Date of next service due
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Date of previous service
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Previous service carried out by
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Valve installed by
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Date of installation
Contractor Sign Off
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Name of Licensed Plumber
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Lic No.
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Signature of Licensed Plumber
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It is hereby certified that all work has been carried out by the undersigned in accordance with the requirements of the HOSPLAN code of Practice for Thermostatic Mixing Valves.
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NOTE: the report is to be retained at the site for any inspection by authorise person
