Clean Water Systems | Add Assessment

A. GENERAL SITE & CLIENT DETAILS

Please enter client and site information

1. Client

2. Client Contact Name

3. Client Contact Telephone No.

4. Client Contact Email Address

5. Site Photograph

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6. Site Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

7. Site Contact Name

8. Site Contact Telephone No.

9. Site Contact Email Address

10. Surveryor

11. Report Ref No.

12. Report Date

13. Review Date

B. BUILDING OVERVIEW

1. Site Description

2. Water Systems Overview

3. Exposed Population

4. Population Vulnerability (Host Susceptibility)

5. Vulnerability Category

6. Notes

ASSESMENT INFORMATION

Please enter assessment & survey details

Survey name

Introduction

Closing statement

Message on completion

Engineer Survey Owner

Engineer Survey Email

Who can view results

Starting date

Closing date

Notes

Analysis

Default question 1

Default question 2

Default question 3

ASSET LIST REGISTER

Please enter assets located on site with correct quantities

COLD WATER STORAGE TANK

How many storage water tanks?

Reference

STORAGE CALORIFIERS

How many storage calorifiers?

Reference

WATER HEATERS

How many water heaters?

Reference

LITTLE USED OUTLETS

How many little used outlets?

Reference

POINT OF USE WATER HEATERS

How many point of use water heaters?

Reference

CLOSED HEATING SYSTEMS

How many closed heating systems?

Reference

SHOWER HEADS

How many shower heads?

Reference

THERMOSTATIC MIXING VALVES

How many thermostatic mixing valves?

Reference

IS THERE OTHERS?

Name of Asset

How many?

Reference

A. COLD WATER STORAGE TANKS

1. Supporting Information

2. Site Observations

3. General Observations and Photographs

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B. COLD WATER STORAGE TANKS - SURVEY

1. Tank Reference

2. Tank Location

3. System served

4. Make up water temperature °C

5. Tank water temperature °C

6. Construction

7. Estimated water storage content in Litres

8. Make-up water source

9. Tank alignment

10. Is there adequate crossflow from inlet & outlet on opposite side of tank??

Make-up & Outlet - Cold Storage Water Tank Advisory

Make-up & Outlet - Scoring Level Risk

11. Is Flow throughput satisfactory?

12. Sparge pipe fitted?

13. Water Supply Regs 1999 closed fitted lid with breathable vent?

Water Supply Regs 1999 lid with vent - Cold Storage Water Tank Advisory

Water Supply Regs 1999 lid with vent - Scoring Level Risk

14. Rodent screen fitted to overflows?

Rodent screen fitted - Cold Storage Water Tank Advisory

Rodent screen fitted - Scoring Level Risk

15. Is there an open vent discharging into the tank?

Open vent discharging - Cold Storage Water Tank Advisory

Open vent discharging - Scoring Level Risk

16. Tank labelling?

17. Effective insulation fitted to Tank?

Effective insulation fitted to Tank - Cold Storage Water Tank Advisory

Effective insulation fitted to Tank - Scoring Level Risk

18. Effective insulation fitted to Pipework?

Effective insulation fitted to Pipework - Cold Storage Water Tank Advisory

Effective insulation fitted to Pipework - Scoring Level Risk

19. Tank complies with Water Supply Regulations 1999 / HSG 274 part 2?

20. Accessibility and ease of cleaning (Access to tank room & around tank)

Good
Average
Poor
Impossible

21. Is ladder needed to inspect?

22. Can tank be isolated from service?

Can tank be isolated - Cold Storage Water Tank Advisory

Can tank be isolated - Scoring Level Risk

23. Are dead-ends / blind-ends evident?

Are dead-ends / blind-ends evident - Cold Storage Water Tank Advisory

Are dead-ends / blind-ends evident - Scoring Level Risk

24. Evidence of stagnation?

Evidence of stagnation - Cold Storage Water Tank Advisory

Evidence of stagnation - Scoring Level Risk

25. Sediment Level

High
Medium
Low

26. Other contaminants

27. Scale level

High
Medium
Low

28. Biocide programme in use?

29. Is there a compliant water hygiene log book on site?

Log Book - Cold Storage Water Tank Advisory

Log Book - Scoring Level Risk

C. COLD WATER STORAGE TANKS - RISK ASSESSMENT

1. Make up source

Mains (not Soft see below) (2)
Soft (Mains or B/X) (0)
Other (e.g. Borehole / Reclaim etc) (10)

2. Capacity

Acceptable for current usage (0)
Over capacity (5)

3. Stored Temperature

Less than 20°C (0)
20°C or above (10)

4. Compliance with Water Supply Regs 1999

Yes (0)
No (10)

Compliance with Water Supply Regs - Cold Storage Water Tank Advisory

Compliance with Water Supply Regs - Scoring Level Risk

5. Appropriate Record Keeping of the Water Hygeine Log Book

Yes (0)
No (10)

Appropriate Record Keeping - Cold Storage Water Tank Advisory

Appropriate Record Keeping - Scoring Level Risk

6. Internal Condition

Good (0) - £ 10.00
Scaled (5) - £ 20.00
Corroded (5) - £ 30.00
Microbiological Fouling (10) - £ 0.00
Stagnation (10) - £ 0.00
Sediment / Debris (5) - £ 0.00
No Safe Access (10) - £ 0.00

7. Total Score

8. Total Score as a % of possible total maximum

9. Final Risk Rating (%) at time of survey

D. RISK RATING

1. Low score percentage

2. High score percentage

E. REMEDIAL ACTIONS REQUIRED

1. Remedial Action

2. Priority Rating

A. STORAGE CALORIFIERS

1. General Observations and Photographs

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2. Supporting Information

3. Site Observations

A. WATER HEATERS

1. General Observations and Photographs

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2. Supporting Information

3. Site Observations

B. WATER HEATERS - SURVEY

1. Water Heater Location

2. Type

3. Condition

Good
Average
Poor

4. Temperature (ºC)

A. LITTLE USED OUTLET FLUSHING

1. Supporting Information

2. Site Observations

3. General Observations and Photographs

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Infrequently used outlets flushed weekly?

Little Used Outlet Flushing Advisory

A. POINT OF USE WATER HEATERS

1. Supporting Information

2. Site Observations

3. General Observations and Photographs

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Number of point of use water heaters on site?

Locations of point of use water heaters

Did temperatures to the POU's achieve 50°

POU Advisory

Any dead legs / blind ends?

POU Advisory

Thermal insulation to pipework evident?

POU Advisory

Is there maintenance service evidence inclusive of internal inspections to each point of use water heater?

POU Advisory

A. CLOSED HEATING SYSTEMS

1. Supporting Information

2. Site Observations

3. General Observations and Photographs

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SHOWER HEADS

Weekly flushed if not in regular use?

Shower Heads Advisory

Shower Head Record Keeping?

Shower Heads Advisory

Shower Head Cleaning & Descaling

Shower Heads Advisory

THERMOSTATIC MIXING VALVES

How many on site?

General Observations and Photographs

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Are they being annually serviced, fail safe and disenfected?

TMV Advisory

Was the thermostatic mixing value temperature between 39-43°C ?

TMV Advisory

Thermal insulation to pipework evident to thermostat mixing value pipework?

TMV Advisory

Are the servicing, fail safe and disinfections being logged and record kept in the water hygeine log book and defects recorded?

TMV Advisory

ENGINEER CONFRIMATION

Please confirm and sign off assessment. Once submitted report will be generated stored and emailed to you directly.

Engineer Assessor

Assessment Confirmation Agreement *I allow this website to collect and store the submitted data.

Signature

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Assessment Portal

A. GENERAL SITE & CLIENT DETAILS

B. BUILDING OVERVIEW

ASSESMENT INFORMATION

ASSET LIST REGISTER

COLD WATER STORAGE TANK

STORAGE CALORIFIERS

WATER HEATERS

LITTLE USED OUTLETS

POINT OF USE WATER HEATERS

CLOSED HEATING SYSTEMS

SHOWER HEADS

THERMOSTATIC MIXING VALVES

IS THERE OTHERS?

A. COLD WATER STORAGE TANKS

B. COLD WATER STORAGE TANKS - SURVEY

C. COLD WATER STORAGE TANKS - RISK ASSESSMENT

D. RISK RATING

E. REMEDIAL ACTIONS REQUIRED

A. STORAGE CALORIFIERS

A. WATER HEATERS

B. WATER HEATERS - SURVEY

A. LITTLE USED OUTLET FLUSHING

A. POINT OF USE WATER HEATERS

A. CLOSED HEATING SYSTEMS

SHOWER HEADS

THERMOSTATIC MIXING VALVES

ENGINEER CONFRIMATION

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