Section J-5-Sample Maint. Task and InspectionForms.pdf

SECTION J-5 SAMPLE MAINTENANCE TASK AND

INSPECTION FORMS

DDESS Maintenance PWS Page 1 of 26 Section J-5 – Sample Maint. /Insp. Forms

3-16-12 Final Quantico, VA

SECTION J-5

SAMPLE MAINTENANCE TASK AND INSPECTION FORMS

1. PREVENTIVE MAINTENANCE

Contractor shall provide Preventive Maintenance work orders and inspection schedules for all equipment and systems included in the facilities listed in Section J-1. Following are samples of the types of documents that could be used.

HEAT PUMP MAINTENANCE SCHEDULE

COMPONENT

TASK

FREQUENCY IN

DAYS

OUTSIDE COIL

INSPECT AND CLEAN

STRAIGHTEN FINS

CHECK FOR DAMAGE OR LEAKS

POWER CLEAN COIL OR CLEAN AS PER MANF. INSTRUCTIONS

OUTSIDE FAN MOTOR

INSPECT AND CLEAN

LUBRICATE

CHECK MOTOR MOUNT RESILIENCY

CHECK OUTSIDE FAN MOTOR INSULATION RESISTANCE

OUTSIDE FAN

INSPECT AND CLEAN

CHECK FOR SECURITY AT MOTOR SHAFT

CHECK ALIGNMENT AND BALANCE

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HEAT PUMP MAINTENANCE SCHEDULE

COMPONENT

TASK

FREQUENCY IN

DAYS

COMPRESSOR

CHECK REFIGERANT CHARGE

CHECK FOR REFRIGERANT AND OIL LEAKS

CHECK CRANKCASE HEATER OPERATION

MEASURE OPERATING VOLTAGE AND CURRENT; RECORD,

COMPARE TO NAMEPLATE INFORMATION

CHECK FOR PROPER OPERATION OF ALL OPERATING AND

SAFETY CONTROLS

FILTER

REPLACE

INSIDE COIL

INSPECT AND CLEAN

STRAIGHTEN FINS

INSPECT AND CLEAN DRAIN PAN AND LINE

POWER CLEAN COIL OR CLEAN AS PER MANF. INSTRUCTIONS

SUPPLY FAN

INSPECT AND CLEAN

CHECK FOR PROPER ROTATION AND CLEARANCE

CHECK SECURITY TO MOTOR SHAFT

SUPPLY FAN MOTOR

INSPECT AND CLEAN

LUBRICATE

CHECK MOTOR MOUNT RESILIENCY

CHECK INSIDE FAN MOTOR INSULATION RESISTANCE

CHECK FAN START CAPACITOR

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HEAT PUMP MAINTENANCE SCHEDULE

COMPONENT

TASK

FREQUENCY IN

DAYS

ELECTRIC HEAT ELEMENTS

CHECK AMP DRAW

CHECK CONDITION OF ELEMENTS

CONTROL PANEL

TEST FOR PROPER OPERATION

TIGHTEN ALL ELECTRICAL CONNECTIONS

SEQUENCE TEST ALL CONTROLS

INSPECT AND CLEAN CONTACTS

DDESS Maintenance PWS Page 4 of 26 Section J-5 – Sample Maint. /Insp. Forms

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FAN COIL UNIT MAINTENANCE SCHEDULE 'L'

COMPONENT

TASK

FREQUENCY IN

DAYS

FAN

INSPECT AND CLEAN

CHECK FOR PROPER ROTATION

TEST FOR VIBRATION

CHECK SHAFT AND END PLAY

CHECK BEARINGS AND LUBRICATE

MOTOR

INSPECT STARTER COILS AND CONTACTS

TIGHTEN ELECTRICAL CONNECTIONS

TEST FOR VIBRATION

LUBRICATE

EXAMINE MOTOR MOUNT RESILIENCY

INSPECT AND ADJUST DRIVE COUPLINGS, PULLEYS AND BELTS

INSPECT FOR CORROSION AND WEAR

CHECK HOUSING CLEARANCE

CHECK ALIGNMENT, BALANCE AND SECURITY TO SHAFT

COOLING COIL

INSPECT AND CLEAN

STRAIGHTEN FINS

CHECK FOR DAMAGE OR LEAKS

INSPECT AND CLEAN CONDENSATE PANS AND DRAINS

COIL PRESSURE CLEANING OR PER MFR INSTRUCTIONS

HEATING COIL

INSPECT AND CLEAN

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CHECK FOR DAMAGE OR LEAKS

COIL PRESSURE CLEANING OR PER MFR INSTRUCTIONS

FILTERS

REPLACE

RETURN AIR DAMPERS

LUBRICATE BEARINGS

CHECK FOR PROPER CLOSE-OFF AND OPERATION

TIGHTEN ANY LOOSE BLADE CONNECTORS

INSPECT BEARINGS FOR EXCESSIVE WEAR

DDESS Maintenance PWS Page 6 of 26 Section J-5 – Sample Maint. /Insp. Forms

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WATER HEATER (GAS-FIRED) MAINTENANCE SCHEDULE 'M'

COMPONENT

TASK

FREQUENCY IN

DAYS

CONTROLS & SAFETY LIMITS

PERFORM OPERATION TESTS AND ASSURE PROPER SETTINGS

OF: OPERATING CONTROL, HIGH TEMPERATURE SAFETY LIMIT,

FLAME-FAILURE SAFETY AND HIGH/LOW GAS PRESSURE

CUTOFF

TIGHTEN CONNECTIONS

INSPECT AND CLEAN CONTACTS

CHECK AND ADJUST FEEDWATER SYSTEM

CHECK AND ADJUST LOW-WATER CUTOFF DEVICE

TEST T&P RELIEF VALVE FOR PROPER OPERATION

BURNER SECTION

CHECK FLAME COMPOSITION AND SHAPE

PERFORM COMBUSTION AND DRAFT TEST

INSPECT AND CLEAN ORIFICES, PASSAGES AND NOZZLES

ADJUST FUEL/AIR RATIO

CHECK AND CLEAN PILOT AND IGNITERS

GAS TRAIN

CHECK FOR PROPER OPERATION OF MAIN AND SAFETY VALVES

CHECK FOR LEAKS AND OVERALL SECURITY

ASSURE GAS VALVE SHUTOFF

CHECK GAS PRESSURE REGULATOR SETTING

TANK

DRAIN AND BLOWDOWN TO REMOVE SCALING

GAUGE

CHECK FOR ACCURACY AND PROPER OPERATION

DDESS Maintenance PWS Page 7 of 26 Section J-5 – Sample Maint. /Insp. Forms

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DDESS Maintenance PWS Page 8 of 26 Section J-5 – Sample Maint. /Insp. Forms

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MAKE-UP AIR UNIT MAINTENANCE SCHEDULE 'N'

COMPONENT

TASK

FREQUENCY IN

DAYS

HOUSING

CHECK MOUNTS FOR SECURITY

CLEAN AND REMOVE EXTERNAL/INTERNAL DIRT ACCUMULATION

FILTERS

REPLACE

BURNER SECTION (FOR GAS-FIRED HEAT)

CHECK FLAME COMPOSITION AND SHAPE

PERFORM COMBUSTION AND DRAFT TEST

INSPECT AND CLEAN ORIFICES, PASSAGES AND NOZZLES

ADJUST FUEL/AIR RATIO

CHECK AND CLEAN PILOT AND IGNITERS

GAS TRAIN (FOR GAS-FIRED HEAT)

CHECK FOR PROPER OPERATION OF MAIN AND SAFETY VALVES

CHECK FOR LEAKS AND OVERALL SECURITY

ASSURE GAS VALVE SHUTOFF

CHECK GAS PRESSURE REGULATOR SETTING

FAN

INSPECT AND CLEAN

CHECK FOR PROPER ROTATION

TEST FOR VIBRATION

CHECK SHAFT AND END PLAY

CHECK BEARINGS AND LUBRICATE

MOTOR

INSPECT STARTER COILS AND CONTACTS

TIGHTEN ELECTRICAL CONNECTIONS

DDESS Maintenance PWS Page 9 of 26 Section J-5 – Sample Maint. /Insp. Forms

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MAKE-UP AIR UNIT MAINTENANCE SCHEDULE 'N'

COMPONENT

TASK

FREQUENCY IN

DAYS

TEST FOR VIBRATION

LUBRICATE

EXAMINE MOTOR MOUNT RESILIENCY

INSPECT AND ADJUST DRIVE COUPLINGS, PULLEYS AND BELTS

INSPECT FOR CORROSION AND WEAR

CHECK HOUSING CLEARANCE

CHECK ALIGNMENT, BALANCE AND SECURITY TO SHAFT

CHECK MOTOR WINDING INSULATION RESISTANCE

MEASURE AND RECORD OPERATING VOLTAGE AND CURRENT - COMPARE TO NAME PLATE DATA

ELECTRIC HEAT ELEMENTS (FOR ELECTRIC HEAT)

CHECK AMP DRAW

INSPECT AND CLEAN ELEMENTS

COOLING COIL

INSPECT FOR DEBRIS AND REMOVE

CLEAN COILW/FLUID AND ALIGN FINS

UV LIGHTS

VERIFY OPERATION

REPLACE LAMPS

CHECK SAFTIES

TIGHTEN ALL CONNECTIONS

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AIR COOLED CONDENSER MAINTENANCE SCHEDULE 'A'

COMPONENT

TASK

FREQUENCY IN

DAYS

FAN

CHECK FOR ALIGNMENT, BALANCE AND SECURITY TO SHAFT

CHECK FOR CORROSION AND WEAR

LUBRICATE BEARINGS AND CHECK FOR END PLAY, EXCESSIVE

BEARING TEMPERATURE AND UNUSUAL BEARING WEAR

CHECK CONDITION OF DRIVE COUPLINGS AND BELTS

CHECK FAN WHEEL AND CLEAN DIRT ACCUMULATION

CHECK AND TIGHTEN MOUNTING BOLTS

CHECK FOR PROPER BELT TENSION

CHECK RAIN SHIELDS

VERIFY UNIT OPERATION

MOTOR

INSPECT STARTER COILS AND CONTACTS

TIGHTEN ALL ELECTRICAL CONNECTIONS

LUBRICATE MOTOR BEARINGS

EXAMINE MOTOR MOUNT RESILIENCY

MEASURE AND RECORD OPERATING VOLTAGE AND CURRENT

RECORD, COMPARE TO NAME PLATE DATA

TEST MOTOR WINDING INSULATION RESISTANCE

CONDENSER COIL

CLEAN FINNED SURFACES WITH WIRE BRUSH OR HIGH

PRESSURE WATER

CHECK FOR DAMAGE OR LEAKS

STRAIGHTEN BENT FINS

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CHECK PIPE CLAMPS FOR SECURITY AND VIBRATION

CHECK FINS FOR DEBRIS AND REMOVE

FRAME

CHECK FOR DAMAGE, RUST AND CORROSION

TREAT FOR CORROSION AS REQUIRED

DDESS Maintenance PWS Page 12 of 26 Section J-5 – Sample Maint. /Insp. Forms

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PUMP MAINTENANCE SCHEDULE 'B'

COMPONENT

TASK

FREQUENCY IN

DAYS

MOTOR

INSPECT AND CLEAN STARTER COILS

INSPECT AND TIGHTEN CONTACTS

TEST FOR VIBRATION

LUBRICATE MOTOR BEARINGS

TEST MOTOR WINDING INSULATION RESISTANCE

MEASURE AND RECORD OPERATING VOLTAGE AND CURRENT

DRAW; COMPARE TO NAME PLATE DATA

COUPLING

CHECK FOR PROPER ALIGNMENT AND CONDITION

INSPECT FOR WEAR AND SHAFT SECURITY

REPLACE IF WORN

LUBRICATE

BEARING ASSEMBLY

LUBRICATE AS REQUIRED

CHECK FOR LEAKS OR WEAR

IMPELLER

REPLACE AS REQUIRED

HOUSING

CHECK PACKAGING AND MECHANICAL SEALS FOR LEAKAGE

INSPECT GASKETS FOR LEAKAGE AND DETERIORATION

LUBRICATE DRIVEN SHAFT BEARINGS

BASE

SECURE MOUNTS

REPLACE IF WORN

DDESS Maintenance PWS Page 13 of 26 Section J-5 – Sample Maint. /Insp. Forms

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CHECK FOR CORROSION

CLEAN AND PAINT

STRAINER

BLOWDOWN STRAINER

REMOVE STRAINER MEDIA AND CLEAN

DDESS Maintenance PWS Page 14 of 26 Section J-5 – Sample Maint. /Insp. Forms

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AIR HANDLING UNIT MAINTENANCE SCHEDULE 'D

COMPONENT

TASK

FREQUENCY IN

DAYS

FAN

INSPECT AND CLEAN

CHECK FOR PROPER ROTATION

TEST FOR VIBRATION

CHECK SHAFT AND END PLAY

CHECK BEARINGS AND LUBRICATE

MOTOR

INSPECT STARTER COILS AND CONTACTS

TIGHTEN ELECTRICAL CONNECTIONS

TEST FOR VIBRATION

LUBRICATE

EXAMINE MOTOR MOUNT RESILIENCY

INSPECT AND ADJUST DRIVE COUPLINGS, PULLEYS AND BELTS

INSPECT FOR CORROSION AND WEAR

CHECK HOUSING CLEARANCE

CHECK ALIGNMENT, BALANCE AND SECURITY TO SHAFT

COOLING COIL

INSPECT AND CLEAN DEBRIS

STRAIGHTEN FINS

CHECK FOR DAMAGE OR LEAKS

INSPECT AND CLEAN CONDENSATE PANS AND DRAINS

COIL POWER CLEAN OR PER MFR INSTRUCTIONS

HEATING COIL

INSPECT AND CLEAN DEBRIS

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CHECK FOR DAMAGE OR LEAKS

COIL POWER CLEAN OR PER MFR INSTRUCTIONS

FACE & BYPASS DAMPERS

LUBRICATE BEARINGS

CHECK FOR PROPER CLOSE-OFF AND OPERATION

TIGHTEN ANY LOOSE BLADE CONNECTORS

FILTERS

REPLACE

RETURN AIR DAMPERS

LUBRICATE BEARINGS

CHECK FOR PROPER CLOSE-OFF AND OPERATION

TIGHTEN ANY LOOSE BLADE CONNECTORS

INSPECT BEARINGS FOR EXCESSIVE WEAR

OUTSIDE AIR DAMPERS

LUBRICATE BEARINGS

CHECK FOR PROPER CLOSE-OFF AND OPERATION

TIGHTEN ANY LOOSE BLADE CONNECTORS

COIL BYPASS

CHECK FOR PROPER OPERATION OF BYPASS

WATER HEATERS (ELECTRIC)

COMPONENT

FREQ.

DAYS

MINUTES PER TASK

MON

THLY

QUAR

TERLY

SEMI

-ANL

ANN

UAL

CONTROLS &

SAFETY LIMITS

TIGHTEN CONNECTIONS

INSPECT AND CLEAN CONTACTS

DDESS Maintenance PWS Page 16 of 26 Section J-5 – Sample Maint. /Insp. Forms

CHECK AND ADJUST FEED WATER

SYSTEM

CHECK AND ADJUST LOW-WATER

CUTOFF DEVICE

TEST T&P RELIEF VALVE FOR

PROPER OPERATION

PERFORM OPERATION TESTS AND

ASSURE PROPER SETTINGS

OF: OPERATING CONTROL, HIGH

TEMPERATURE SAFETY LIMIT,

FLAME-FAILURE SAFETY AND

HIGH/LOW GAS PRESSURE

CUTOFF

ELECTRIC

HEATER

SECTION

CHECK CURRENT ON EACH HEATER

(RECORD/COMPARE)

TANK

DRAIN AND BLOW DOWN TO

REMOVE SCALING

GAUGE

CHECK FOR ACCURACY AND

PROPER OPERATION

DDESS Maintenance PWS Page 17 of 26 Section J-5 – Sample Maint. /Insp. Forms

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FOOD SERVICE WALK-IN COOLER/FREEZER 'I'

COMPONENT

TASK

FREQUENCY IN

DAYS

MOTOR

CHECK CURRENT

LUBRICATE MOTOR BEARINGS

FAN

INSPECT AND CLEAN

CHECK FOR PROPER ROTATION, ALIGNMENT AND BALANCE

TEST FOR VIBRATION

COMPRESSOR

CHECK REFRIGERANT CHARGE

CHECK FOR REFRIGERANT AND OIL LEAKS

VALVES

INSPECT AND REPLACE AS REQUIRED

CONDENSER COIL

CHECK FOR DEBRIS AND REMOVE

CLEAN COIL W/FLUID AND ALIGN FINS

EVAPORATOR COIL

CHECK FOR DEBRIS AND REMOVE

CLEAN COIL W/FLUID AND ALIGN FINS

DDESS Maintenance PWS Page 18 of 26 Section J-5 – Sample Maint. /Insp. Forms

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AIR COOLED CHILLER SCHEDULE 'J1'

COMPONENT

TASK

FREQUENCY IN

DAYS

CONTROL CENTER

CALIBRATE AND CLEAN CONTROLS AND SAFETY DEVICES

INSPECT, CLEAN AND TIGHTEN ELECTRICAL CONTACTS

CHECK SET POINT OF CONTROLS AND LIMITS

SEQUENCE TEST ALL CONTROLS

TEST TEMPERATURE AND PRESSURE CONTROLS

VANES

CHECK FOR PROPER OPERATION

LUBRICATE VANE LINKAGES

CHECK VANE CONTROL FOR PROPER OPERATION

COMPRESSOR

CHECK REFRIGERANT CHARGE AND FOR RFRGT. AND OIL LEAKS

TEST FOR PROPER OPERATION AND EFFICIENCY

OBSERVE BEARING AND OPERATING SURFACE TEMPS AND RECORD

TEMPERATURES AND REPORT THOSE OUTSIDE NORMAL OPERATION

PERFORM AND MEASURE ACID TEST

MEASURE VIBRATION ON MAIN BEARINGS

CHECK OIL LEVEL AND CONDITION

CHECK OIL HEATER OPERATION

IMPELLER

MEASURE VIBRATION (WHERE APPLICABLE)

MOTOR

MEASURE OPERATING CURRENT AND VOLTAGE; RECORD,

COMPARE TO NAMEPLATE DATA

DDESS Maintenance PWS Page 19 of 26 Section J-5 – Sample Maint. /Insp. Forms

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AIR COOLED CHILLER SCHEDULE 'J1'

COMPONENT

TASK

FREQUENCY IN

DAYS

LUBRICATE MOTOR BEARINGS

EXAMINE MOTOR MOUNT RESILIENCY

CHECK MOTOR INSULATION RESISTANCE

CHECK CONDITION AND ALIGNMENT OF DRIVE SECTION

TRANSMISSION (WHERE APPLICABLE)

CHECK FOR PROPER LUBRICATION

LUBRICATION PUMP

INSPECT AND CHECK FOR PROPER OPERATION

CHECK OIL HEATER FOR PROPER OPERATION

CHANGE OIL AND FILTER

TEST OPERATION OF OIL PUMP

VIBRATION ISOLATORS

CHECK FOR CORROSION AND FATIGUE

PURGE UNIT

LUBRICATE MOTOR

CLEAN PURGE DRUM

CHANGE PURGE UNIT OIL

CHECK DRIVE BELT AND ADJUST TENSION (WHERE APPLICABLE)

FLOW CONTROL

CHECK FLOAT CONTROL OPERATION

COOLER

INSPECT RUPTURE DISC FOR LEAKS

INSPECT AND CLEAN TUBES

ELIMINATOR

CHECK FOR PROPER REFRIGERANT LEVEL IN COOLER

DDESS Maintenance PWS Page 20 of 26 Section J-5 – Sample Maint. /Insp. Forms

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AIR COOLED CHILLER SCHEDULE 'J1'

COMPONENT

TASK

FREQUENCY IN

DAYS

CHILLED WATER CONNECTION

CLEAN ALL WATER STRAINERS IN WATER PIPING SYSTEM

CHECK FOR LEAKS AT CONNECTION, REPAIR OR TIGHTEN AS REQ'D.

FAN

CHECK FOR ALIGNMENT, BALANCE AND SECURITY TO SHAFT

CHECK FOR CORROSION AND WEAR

LUBRICATE BEARINGS AND CHECK FOR END PLAY, EXCESSIVE

BEARING TEMPERATURE AND UNUSUAL BEARING WEAR

CHECK FAN WHEEL AND CLEAN DIRT ACCUMULATION

CHECK AND TIGHTEN MOUNTING BOLTS

CHECK RAIN SHIELDS

VERIFY UNIT OPERATION

CONDENSER COILS

INSPECT AND CLEAN FINS

INSPECT FOR CORROSION

INSPECT AND TREAT FOR CORROSION AND PAINT AS REQUIRED

STARTER

CHECK OVERLOAD SETTING TRIP POINT AMPS

TIGHTEN ALL TERMINALS

CHECK CONDITION OF STARTER CONTACTS

DDESS Maintenance PWS Page 21 of 26 Section J-5 – Sample Maint. /Insp. Forms

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WATER COOLED CHILLER SCHEDULE 'J'

COMPONENT

TASK

FREQUENCY IN

DAYS

CONTROL CENTER

CALIBRATE AND CLEAN CONTROLS AND SAFETY DEVICES

INSPECT, CLEAN AND TIGHTEN ELECTRICAL CONTACTS

CHECK SET POINT OF CONTROLS AND LIMITS

SEQUENCE TEST ALL CONTROLS

TEST TEMPERATURE AND PRESSURE CONTROLS

VANES

CHECK FOR PROPER OPERATION

LUBRICATE VANE LINKAGES

CHECK VANE CONTROL FOR PROPER OPERATION

COMPRESSOR

CHECK REFRIGERANT CHARGE AND FOR RFRGT. AND OIL LEAKS

TEST FOR PROPER OPERATION AND EFFICIENCY

OBSERVE BEARING AND OPERATING SURFACE TEMPS AND

REPORT TEMPERATURES OUTSIDE NORMAL OPERATION TO KO

PERFORM AND MEASURE ACID TEST

MEASURE VIBRATION ON MAIN BEARINGS

CHECK OIL LEVEL AND CONDITION

CHECK OIL HEATER OPERATION

IMPELLER

MEASURE VIBRATION

MOTOR

MEASURE OPERATING CURRENT AND VOLTAGE; RECORD,

COMPARE TO NAMEPLATE DATA

DDESS Maintenance PWS Page 22 of 26 Section J-5 – Sample Maint. /Insp. Forms

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WATER COOLED CHILLER SCHEDULE 'J'

COMPONENT

TASK

FREQUENCY IN

DAYS

LUBRICATE MOTOR BEARINGS

EXAMINE MOTOR MOUNT RESILIENCY

CHECK MOTOR INSULATION RESISTANCE

CHECK CONDITION AND ALIGNMENT OF DRIVE SECTION

TRANSMISSION

CHECK FOR PROPER LUBRICATION

LUBRICATION PUMP

INSPECT AND CHECK FOR PROPER OPERATION

CHECK OIL HEATER FOR PROPER OPERATION

CHANGE OIL AND FILTER

TEST OPERATION OF OIL PUMP

VIBRATION ISOLATORS

CHECK FOR CORROSION AND FATIGUE

PURGE UNIT

LUBRICATE MOTOR

CLEAN PURGE DRUM

CHANGE PURGE UNIT OIL

FLOW CONTROL

CHECK FLOAT CONTROL OPERATION

COOLER

INSPECT RUPTURE DISC FOR LEAKS

INSPECT AND CLEAN TUBES

ELIMINATOR

CHECK FOR PROPER REFRIGERANT LEVEL IN COOLER

DDESS Maintenance PWS Page 23 of 26 Section J-5 – Sample Maint. /Insp. Forms

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WATER COOLED CHILLER SCHEDULE 'J'

COMPONENT

TASK

FREQUENCY IN

DAYS

CHILLED WATER CONNECTION

CLEAN ALL WATER STRAINERS IN WATER PIPING SYSTEM

CHECK FOR LEAKS AT CONNECTION, REPAIR OR TIGHTEN AS REQ'D.

CONDENSER WATER CONNECTIONS

CHECK FOR LEAKS AT CONNECTION, REPAIR OR TIGHTEN AS REQ'D.

CONDENSER

INSPECT AND CLEAN TUBES

INSPECT FOR CORROSION

INSPECT AND TREAT FOR CORROSION AND PAINT AS REQUIRED

STARTER

CHECK OVERLOAD SETTING TRIP POINT AMPS

TIGHTEN ALL TERMINALS

CHECK CONDITION OF STARTER CONTACTS

DDESS Maintenance PWS Page 24 of 26 Section J-5 – Sample Maint. /Insp. Forms

2. INSPECTIONS

Contractor shall provide Inspection for where the service is required in this PWS. Inspection forms shall be included for required components in the facilities listed in Section J-1. Following is a sample of the type of document that could be used.

DDESS Maintenance PWS Page 25 of 26 Section J-5 – Sample Maint. /Insp. Forms

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General Roof Conditions Debris on Roof Drainage Physical Damage Attic Conditions Structural Deformation Other Flat / Membrane Roof Condition of Coating Granular Loss Punctures Cracks / Alligatoring Blisters / Fishmouths Ponding Other Sloped Roof Roof Material Condition of Surface Deformed Edges Shingle: Buckled Curled Missing Tabs Granular Loss Other Metal: Corrosion Fasteners Other Roof Features Fascia Soffit Flashing Gutters / Drains, etc.

Skylights Chimneys / Vents Fall Arrest Anchors Control Zone Access Other

Cracks Water Staining Water Leaks Seasonal Change Other

Deformed Finish Surface Deterioration Staining Other

Cracks Water Staining Water Leaks Deformed Finish Seasonal Change Window Leaks Door/Window Alignment Other

ROOF INSPECTION CHECKLIST

Ceiling Conditions

Exterior Wall Surfaces

Interior Wall Surfaces

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Facility Name:______________________________ Bldg. #:_______________________________

Type of Roof Flat / Membrane / Metal / Composition Tile: __________________ Sloped: __________Slope:________in 12

Construction / Re-roofing / Repair Dates: __________________________________________

Inspected by: __________________ Date: ____________________

ROOF INSPECTION CHECKLIST

Summary/Comments

(Highlight areas of concern and any rapid degradation in roof system)

Comment on changes from previous inspections and overall roof condition. Indicate recommended action of roof repair and/or further assessment and estimated remaining life expectancy of room system. Include any photographs and thermolgraphy records in their rreport.