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Appendix D – Ventilator Start-Up Inspection and Tests, Page D-8_________________________________
Page 6 of 6
Ventilator Start-Up Inspection and Test Report
For Gaylord Model CG3-UVi-SPC Series Ventilators
Instructions from the Gaylord Certified Service Agency to the Owner/Operator/End User
After the Inspection and Tests has been successfully completed, demonstrate and review the following
with the Owner/Operator/End User.
1.
Explain the Principles of Operation as shown on pages 2-1 through 2-12 ………………………. _____ (CSA
Initial)
2.
Review the Operator Maintenance and Cleaning Instructions as described on page. … ____ (CSA Initial)
3.
Explain that the Ventilator and UV System must be on a scheduled maintenance program, in
accordance with NFPA-96, and that it can only be performed by a Certified Service Agency. ____ (CSA
Initial)
4.
Explain the hazards of UV light if the Owner/Operator/End User services the UV System. ____ (CSA
Initial)
5.
Provide a copy of the Gaylord Technical Manual for the CG3-UVi-SPC Series Ventilator. …. ____ (CSA
Initial)
6.
Provide a copy of the Gaylord Command Center Technical Manual. ………………………….____ (CSA Initial)
7.
Provide a copy of this Start-Up Inspection and Test Report. ……………………………………… ____ (CSA Initial)
Note to Operator:
You may obtain a free copy of the Gaylord Technical Manual for the CG3-UVi-SPC
Series Ventilator and the Gaylord Command Center Technical Manual by visiting
Owner/Operator/End User Acknowledgement
Please sign this form to acknowledge that the Gaylord Certified Service Agent has thoroughly explained
items 1 through 4 above, and provided documents listed in items 5 through 7 above.
Signature ________________________________________________________________
Print Name _______________________________________________________________
Company Name ___________________________________________________________
Title ______________________________________________________ Date __________
Comments
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Gaylord Industries – 10900 SW Avery St. – Tualatin, OR 97062 USA