Diagnostic Inspection Checklist_2025.09.26.pdf

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MARCH 13, 2025

NEBRASKA ARMY NATIONAL GUARD

of For Official Use Only

DIAGNOSTIC INSPECTION CHECKLIST

NEBRASKA NATIONAL GUARD

Contracting Office Joint Forces Headquarters Suite 2200 Contract W91243-26-X-XXXX

I. INFORMATION

a. FACILITY/LOCATION

b. DATE INSPECTED

c. EQUIPMENT TYPE

d. MANUFACTURER

e. MODEL

f. SERIAL #

II. GENERAL INSPECTION CHECKLIST

Inspection Item Result Deficiencies Photo Reference # Pass Fail Minor Major Critical N/A Equipment Data Plate/Serial Verified Notes:

Visual Condition (Damage, Corrosion, Leaks) Notes:

Electrical Safety (Grounding, Wiring) Notes:

Gas/Propane Line Safety Notes:

Operational Test (Cycle Run) Notes:

OSHA/ANSI/NFPA Compliance Notes:

III. EQUIPMENT-SPECIFIC CHECKLIST

a. Refrigeration & Freezers Inspection Item Result Deficiencies Photo Reference # Pass Fail Minor Major Critical N/A Condenser/Evaporator Coils Cleaned Notes:

Refrigerant Levels/Pressures Checked Notes:

Door Seals/Gaskets Condition Notes:

Defrost Cycle & Drain Verified Notes:

Insulation Condition Notes:

Temperature Set Point vs Actual Notes:

Set Point:

Actual:

b. Cooking Equipment Inspection Item Result Deficiencies Photo Reference # Pass Fail Minor Major Critical N/A Burners/Ignitors Inspected and Tested Notes:

Safety Interlocks Functional Notes:

Filters, Fans, Valves Cleaned Notes:

Door Seals/Gaskets Condition Notes:

Test Wells and Drain Lines Verified Notes:

Water Faucet/Fill Points Notes:

Thermostat Calibration Results Notes:

Set Point:

Actual:

c. Ice Machines & Bins Inspection Item Result Deficiencies Photo Reference # Pass Fail Minor Major Critical N/A Coils Cleaned and Sanitized Notes:

Thermostat Tested Notes:

Water Filtration/Drainage System Inspected Notes:

Bin Sanitation Notes:

Electrical & Safety Cutoffs Tested Notes:

Ice Production (lbs/Day vs Mfr. Rating) Notes:

Actual:

Rated:

IV. ADDITIONAL NOTES

5. DETERMINATION (explain the above)

V. SIGNATURES

a. I certify that the above inspection was conducted in accordance with contract requirements, industry standards, and manufacturer specifications.

b. TECHNICIAN NAME

c. DATE 11.0.0.20130303.1.892433.887364