FORM PENGAJUAN

TEST & COMMISSIONING

(LOGO PROYEK)

FAN
:

Test

Project
Proyek

:
:

Package
Paket

Uji

Kinerja Fan

Date of Test
Tanggal Uji

Location
Lokasi

Drawing Reff.
Referensi Gbr

I. Power Consumption & Performance of Electrical Panels

:
I.1. LOCATION
A. a. Floor / Zone

Fan Performance

b. Type

c. No.

:
Test Result
Accepted

B. Power Consumption & Quality of Installation

Rejected

Remarks

a. Voltage Incoming power supply (Incoming Direction)

MCCB / MCB :

...Volts

b. Voltage Outgoing power supply (Outgoing Direction)

MCCB / MCB :

...Volts

c. Voltage Incoming field power supply (Incoming Direction)

MCCB / MCB :

...Volts

d. Power Consumption Fan only

...Volts

e. Function after thermostat

f. Function of start button
g. Function of stop button
h. Function of Fan / Coil button
I. Function of drain considering water with U-trap
II. Attachment

REMARKS

II.1
II.2
II.3
II.4
II.5
III. Summary of Testing & Commissioning

COMMENT

ACCEPTED

Diperiksa oleh,
Kontraktor Utama
PT. .

Diperiksa oleh,
Kontraktor Spesialis / NSC / DC
PT.

Diajukan oleh,
Supplier
PT. ...

(.)

(.)

(.)

Disetujui Oleh,
PT. ..
Property Management
Project Management

( .)

333219060.xls

(..)

QMS/DCC/FML-HOV/08 (R.00) - 310805

REJECTED