Title Page

  • Store Name & Store Number

  • Location

  • Work Order No:

  • Conducted on

  • Prepared by

Inspection Details: PHOTOGRAPHIC EVIDENCE REQUIRED AS PROOF OF INSPECTION. You must take before & after pictures of components replaced/rectified etc.

Liquid Receivers

  • Does site have receivers?

  • How Many Receivers are on Site?

  • Liquid receiver details

  • Receiver
  • Manufacturer:

  • Receiver Model /Serial Number(Picture)

  • Receiver Model /Serial Number(Input text)

  • Type of Receiver:

  • Location of Receiver:

  • Physical Condition:

  • General Comment on Receivers


  • How many Pressure Relief Valves are on Site?

  • How many Pressure Relief Valve require replacement as per report provided Woolworths?

  • Pressure Relief Valve details

  • Valve
  • Pressure Valve No :1

  • Do you have Replacement valve ?

  • Have you replaced valve?

  • General Comment:

  • Design Pressure Rating? PA or PSI

  • Pressure Relief Gauge fitted?

  • Add media

  • Is the Pressure Relief Gauge at Zero:

  • Has Burst Disc Failed?

  • Supporting Picture

  • Has Valve Seal Broken?

  • Supporting Picture

  • Vented to Atmosphere: Yes / No *If No, What is required to establish Vent: H.D Pipe / Fittings Size / Requirements:

  • Does PRV vent to Atmosphere?

  • What is required (Scope of work) to vent outside?


  • Note: HVAC MSSB should contain supply C/B for Heater Banks - Amps to be measured at supply

  • Does site have electric duct heaters?

  • How Many Duct heaters are on-site?


  • Electric Duct Heater Bank No1: Operational

  • Power Supply to Electric Duct Heater Bank No1

  • Running Amps?

  • Electric Duct Heater Bank No1- Location:

  • Are Heaters Accessible: Yes / No *If No, what is required to access - comment + photos + dimensions:

  • Any Loose Connections? or discolored or sign of deterioration on connections

  • Evidence via Picture

  • Does heater Require Replacement?

  • Details on replacement

  • Thermal Coating Compromised

  • General Comments if any?


  • What type of equipment is on site which serves the trading floor?

  • Plant Type?

  • Type of refrigerant ?

  • General Condition (Visual inspection)

  • Pictures of the component

  • DX Plant Compressors:
  • Compressor Location?

  • Make:

  • Model:

  • Pictures of Compressors


  • How Many Condensers are on site?

  • What is the condition of Condensers?

  • Pictures of the Condensers.

  • General Comment

HVAC Controller

  • What Type of HVAC controller is on-site?

  • Picture of MSSB & Controller

  • General Comment:


  • Have you completed Maintenance Authority form?

  • Picture of MA

  • Have you cleaned up your work area which includes removal of all rubbish?

  • Name & Sign off

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.