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Version 1, 15 June 2020, 13 of 16
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APPENDIX
Galvin Engineering Thermostatic Mixing Valve or
Tempering Valve Commissioning Report and/or
Maintenance Report
Note:
1.
Please use a separate form for each valve.
2.
The original copy of the report is to be given to the owner/occupier and retained on site for a minimum of 7 years.
Cross off appropriate box
□
Thermostatic Mixing Valve
□
Tempering Valve
□
Commissioning Report
□
Maintenance Report
□
Name of Establishment: ____________________________________________________________________
Address of Establishment: ______________________________________________________________________
Phone Number: _____________________________ Date: _____________________ Work Order #: _______
Contact Person: _______________________ Make & Model of Hot Water System: ________________ ______
Temperature of Hot Water to the Valve: ____________ Temperature of Cold Water to the Valve: ______________
Hot Water Pressure: ________kPa Cold Water Pressure: _______kPa
Make of Mixing Valve: _______________________ Model No: ________________________ Size: _________
Valve Location/Building: _____________________________________________________________________
Valve Identification No: ______________________________________________________________________
Total No of Valves on the Site/Building: _________________________________________________________
No of Outlets Serviced by this Valve: Baths ( ) Basins ( ) Showers ( )
Other Outlets - Details ______________________________________________________________________
Valves Installed to the requirements of:
The NSW Code of Practice Plumbing and Drainage
Yes
No
The HOSPLAN Code of Practice for Thermostatic Mixing Valves in Health Care
Facilities
Yes
No
The Valves manufacturers requirements
Yes
No
AS4032.3
Yes
No
The specifications and drawings for the project
Yes
No
The Local Water Supply or Authority
Yes
No
If No, give details and actions taken:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________
