Thermostatic Mixing Valve AP

• THERMOSTATIC MIXING VALVE COMMISSIONING/TEST REPORT

• Document No.

• Audit Title (site address / year)

Thermostatic Mixing Value - Commission / Maintenance Report

Site Information

• Name of Establishment

• Address
  Address

• Contact Name

• Contact Phone Number

Make of TMV

• Make of TMV

• Model No.

• Serial Number

• Valve Location

Number of Fixtures Serviced by This Valve

• Basins

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Showers

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Baths

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Other (note details below)

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Description of other items

Mixing Valves installed in compliance with requirements of:

• A. Drawings and specifications

  Yes

  No

  NA

• B. Manufacturers installation instructions

  Yes

  No

  NA

• C. Relevant code of practice (Hos Plan)

  Yes

  No

  NA

• D. Water supply standards

  Yes

  No

  NA

• If no, provide reason & action taken

Work Carried Out This Visit

• Dismantled

• Thermostat Element Replaced

• Serviced

• O Ring Replaced

• Components Inspected and Cleaned

• Commissioned

• Non Return Valves Checked

• Temperature Set

Thermal Shutdown Test

• Hot/Cold water failure test

  Passed

  Failed

  NA

• Failure test numbers (temp/pressure)

Temp hot/cold, Pressure hot/cold

• Temperature of Water Supply - Hot

• Dynamic Pressure of Water Supply - HOT (KPA)

• Temperature of Water Supply - Cold

• Dynamic Pressure of Water Supply - COLD (KPA)

• Temperature of water at TMV at Outlet - (Degrees)

• If fail, provide actions taken

Install/Service Information

• Date of Installation

  Date

• Valve Installed By

• Date of Commissioning

  Date

• Valve Commissioned By

• Date of Service

  Date

• Valve Serviced By

• Next Service Date

  Date

• Additional information

Licensee Details

• Signature of Licensed Plumber

  Sign

• Licence No.