Thermostatic Mixing Valves Commissioning Report

• Client / Site

• Report No.

• Date of Inspection

  Date
• Address of Establishment
  Address

• Contact Person and Phone Number

• Prepared by

Valve Information and Testing Results

• Make of Mixing Valve

• Model

• Valve Size

• Valve Location/Building

• Valve Identification Number

• Photo of Valve

  Media

• Total number of outlets served by this valve

• Baths

• Basins

• Showers

• Other outlets

• Details of other outlets

• Temperature of mixing valve outlets in °C

• Fail Safe Test

  PASSED

  FAILED

• Valve considered satisfactory for further use?

  YES

  NO

• Temperature as on plan or in spec. In °C

• Temperature as in HOSPLAN (referred to as the Code of Practice) page 54; section 7:
  For Adults - 40.5 to 43.5°C
  For Children - 38 to 40.5°C
  For Neonatals (babies) - 35 to 38°C

• Dynamic hot water pressure in kPa

• Dynamic cold water pressure in kPa

• Installing Company Details:
  ON THE GO PLUMBING SERVICES PTY LTD
  PO Box 88
  Panania NSW 2213
  Phone: 0404 602 057
  Contract Authority: 222880C

• Name of accredited tester

• Accreditation Number

• Temperature checked and Fail/Safe witnessed by

• Employed by

• Position held

• Testers Signature

  Sign