Quarterly Test & Inspection Site Evacuation System Certificate

• Client:

• Site Name (Phase/Block):

• Contract Number:

• Date:

  Date

• Carried out by:

• Quarterly Inspection (A, C)

• Annual Inspection (A, C)

C - System Inspection/Servicing Report

• Extent of the evacuation system covered by this report:

• Agreed Limitation, if any, on the inspection and servicing:

OVER A QUARTERLY PERIOD

• Visual devices check

• Devices accessbible

• Auto dialer operational (where applicable)

OVER A 12 MONTH PERIOD

• Switch mechanism of every call point

• All devices checked for correct operation

• Standby power supplies provided (mains voltage)

• Standby power supplies (battery check)

• Existing records checked

• Log book available

I/we declare that in my/our judgement, the said system was in overall in the below stated condition at the time the inspection and servicing was carried out, and that it should be further inspected as recommended (see below). * (Insert 'a satisfactory' or 'an unsatisfactory' as appropriate):

• Satisfactory

  Unsatisfactory

  N/A

  Requires Improvement

• Full Name

• Signature

  Sign

• Position

• Date

  Date
Summary of Inspection & Servicing

• (Insert comments as necessary)

• Number of outstanding defects reported to responsible person