Title Page
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Conducted on
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Name of Surveyor
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Landlord Name
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Survey Address
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Describe property type
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Is there any tenant, resident or regular visitor particularly susceptible to Legionella due to age, health or lifestyle
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Describe type of cold water system e.g mains feed or from storage tank
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Describe type of hot water system
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1. Is cold water temperature at outlets below 20 degree celsius
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Is the hot water temperature at 50 degrees celsius at outlets
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2. Cold water storage tanks. Is there one present
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If YES Location (Cold water storage tanks)
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Does it have a tight fitting lid?
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Is the water in the tank clean and free from rust, debris, scale and organic matter?
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Is the tank insulated?
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3. Hot water. Is the temperature setting on the boiler and/or hot water such that the hot water is heated to and stored at a temperature of 60 degrees celsius?
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4. Little used outlets. Are there any water outlets that are used less than once per week e.g. In guest bathrooms/outbuildings.
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If YES specify outlet type and location
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5. Shower heads and houses. Are there any in the property?
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If yes how many and location.
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6. Are there any dead legs in the property/building?
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If YES specify location (s)
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8. Has advice been given to the tenants/occupants as to the risks of Legionnaires Disease in the building/premise and their responsibility to minimise risk?
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Notes/action to take
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Conclusion after survey is that the risk of the spread and growth of the Legionnaires bacteria in this property:
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The assessment is complete and should be reviewed regularly (at least once a year or as advised by the assessor) and specifically when there is reason to suspect it is no longer valid. You should ensure that the recommendations above are implemented and any existing controls are maintained.
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