Survey form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Calorifiers

• Is there a calorifier present?<br>

  Yes

  No

  N/A

• Reference

• Does it comply to L8<br>

  Yes

  No

  N/A

• Add media

  Media

• Type

• Approximate volume L?

• Circulated water system?

  Yes

  No

  N/A

• Comments

CWST

• Number?

• Supplies?

• L8 compliant?<br>

  Yes

  No

  N/A

• Add media

  Media

• Size?

• Description or comments?

Outlets

• System description

• No. Of outlets?

• Showers present?<br>

  Yes

  No

  N/A

General information

• Schematic drawings on site?

  Yes

  No

  N/A

• Risk assessment on site?

  Yes

  No

  N/A

• Log book on site?

  Yes

  No

  N/A

• Comments, observations

• Softener in use for hot water?<br>

  Yes

  No

  N/A

• Type

• Add media

  Media

• Steam boilers on site?<br>

  Yes

  No

  N/A

• No. Of boilers?

• Type?

• Description

• Add media

  Media

• Are they operated by Synergy?

  Yes

  No

  N/A

• Chemical supply required?

  Yes

  No

  N/A

• Current chemicals in use?

• Bulk delivery?

  Yes

  No

  N/A

• 25l drum delivery?

  Yes

  No

  N/A

• Softener present?<br>

  Yes

  No

  N/A

• Softener type?

• Comments

• Wash disinfector present?<br>

  Yes

  No

  N/A

• No. Of washer disinfectors?

• Sterilisers present?

  Yes

  No

  N/A

• No. Of sterilisers?

• Are the sterilisers fed from a common steam supply?<br>

  Yes

  No

  N/A

• Is the steam plant within 50m of the sterilisers?

  Yes

  No

  N/A

• Do any sterilisers have there own clean steam generation?<br>

  Yes

  No

  N/A

• Softener present?

  Yes

  No

  N/A

• Does the softener feed the RO only?

  Yes

  No

  N/A

• Type

• Add media

  Media

• RO plant present?

  Yes

  No

  N/A

• Type

• Description

• Add media

  Media

• Description

• Number of clean rooms?