Commissioning Form
Customer Company Name
*
Customer Name
*
Customer Phone Number
*
Mobile Number
Customer E-mail
*
Number of Air+Surface Sterilizers
*
1
2
3
4
5
None
Product Model 1
*
Please Select
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS50G
PRO AS180
ASENS+ 20i
ASENS+ 40i
VERSA 45s
Serial Number 1
*
Placement/Location of Unit 1
*
Label 1
Air+Surface Sterilizers Checklist 1
*
Yes
No
Machine ON/OFF
Presence of Ozone
Air+Surface Sterilizers 1
*
Product Model 2
*
Please Select
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS50G
PRO AS180
ASENS+ 20i
ASENS+ 40i
VERSA 45s
Serial Number 2
*
Placement/Location of Unit 2
*
Label 2
Air+Surface Sterilizers Checklist 2
*
Yes
No
Machine ON/OFF
Presence of Ozone
Air+Surface Sterilizers 2
*
Product Model 3
*
Please Select
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS50G
PRO AS180
ASENS+ 20i
ASENS+ 40i
VERSA 45s
Serial Number 3
*
Placement/Location of Unit 3
*
Label 3
Air+Surface Sterilizers Checklist 3
*
Yes
No
Machine ON/OFF
Presence of Ozone
Air+Surface Sterilizers 3
*
Product Model 4
*
Please Select
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS50G
PRO AS180
ASENS+ 20i
ASENS+ 40i
VERSA 45s
Serial Number 4
*
Placement/Location of Unit 4
*
Label 4
Air+Surface Sterilizers Checklist 4
*
Yes
No
Machine ON/OFF
Presence of Ozone
Air+Surface Sterilizers 4
*
Product Model 5
*
Please Select
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS50G
PRO AS180
PRO AS150DF
ASENS+ 20i
ASENS+ 40i
VERSA 45s
Serial Number 5
*
Placement/Location of Unit 5
*
Label 5
Air+Surface Sterilizers Checklist 5
*
Yes
No
Machine ON/OFF
Presence of Ozone
Air+Surface Sterilizers 5
*
Number of Distributed Sterilization Systems
*
1
2
3
4
5
None
Product Model 1
*
Please Select
PRO AS150D
PRO AS200
PRO AS300D
PRO AS500D
PRO AS750D
PRO AS1000D
Serial Number 1
*
Placement/Location of Unit 1
*
Label 1
Nozzle LPM 1
*
ON/OFF Timinig 1
*
Distributed Sterilization Systems Checklist 1
*
Yes
No
Machine ON/OFF
Presence of Ozone
Distributed Sterilization Systems 1
*
Product Model 2
*
Please Select
PRO AS150D
PRO AS300D
PRO AS500D
PRO AS750D
PRO AS1000D
Serial Number 2
*
Placement/Location of Unit 2
*
Label 2
Nozzle LPM 2
*
ON/OFF Timinig 2
*
Distributed Sterilization Systems Checklist 2
*
Yes
No
Machine ON/OFF
Presence of Ozone
Distributed Sterilization Systems 2
*
Product Model 3
*
Please Select
PRO AS150D
PRO AS300D
PRO AS500D
PRO AS750D
PRO AS1000D
Serial Number 3
*
Placement/Location of Unit 3
*
Label 3
Nozzle LPM 3
*
ON/OFF Timinig 3
*
Distributed Sterilization Systems Checklist 3
*
Yes
No
Machine ON/OFF
Presence of Ozone
Distributed Sterilization Systems 3
*
Product Model 4
*
Please Select
PRO AS150D
PRO AS300D
PRO AS500D
PRO AS750D
PRO AS1000D
Serial Number 4
*
Placement/Location of Unit 4
*
Label 4
Nozzle LPM 4
*
ON/OFF Timinig 4
*
Distributed Sterilization Systems Checklist 4
*
Yes
No
Machine ON/OFF
Presence of Ozone
Distributed Sterilization Systems 4
*
Placement/Location 5
*
Please Select
PRO AS150D
PRO AS300D
PRO AS500D
PRO AS750D
PRO AS1000D
Serial Number 5
*
Placement of Unit 5
*
Label 5
Nozzle LPM 5
*
ON/OFF Timinig 5
*
Distributed Sterilization Systems Checklist 5
*
Yes
No
Machine ON/OFF
Presence of Ozone
Distributed Sterilization Systems 5
*
Number of Ozone Water Systems
*
1
2
3
4
5
None
Product Model 1
*
Please Select
O3 Hydro 5
O3 Hydro 10
O3 Hydro 20
O3 Hydro 30
Serial Number 1
*
Placement/Location of Unit 1
*
Label 1
Ozone Water Systems Checklist 1
*
Yes
No
Machine ON/OFF
Quick Plug attached
Presence of Ozone
Ozone Water Flow
Ozone Water Systems 1
*
Product Model 2
*
Please Select
O3 Hydro 5
O3 Hydro 10
O3 Hydro 20
O3 Hydro 30
Serial Number 2
*
Placement/Location of Unit 2
*
Label 2
Ozone Water Systems Checklist 2
*
Yes
No
Machine ON/OFF
Quick Plug attached
Presence of Ozone
Ozone Water Flow
Ozone Water Systems 2
*
Product Model 3
*
Please Select
O3 Hydro 5
O3 Hydro 10
O3 Hydro 20
O3 Hydro 30
Serial Number 3
*
Placement/Location of Unit 3
*
Label 3
Ozone Water Systems Checklist 3
*
Yes
No
Machine ON/OFF
Quick Plug attached
Presence of Ozone
Ozone Water Flow
Ozone Water Systems 3
*
Product Model 4
*
Please Select
O3 Hydro 5
O3 Hydro 10
O3 Hydro 20
O3 Hydro 30
Serial Number 4
*
Placement/Location of Unit 4
*
Label 4
Ozone Water Systems Checklist 4
*
Yes
No
Machine ON/OFF
Quick Plug attached
Presence of Ozone
Ozone Water Flow
Ozone Water Systems 4
*
Product Model 5
*
Please Select
O3 Hydro 5
O3 Hydro 10
O3 Hydro 20
O3 Hydro 30
Serial Number 5
*
Placement/Location of Unit 5
*
Label 5
Ozone Water Systems Checklist 5
*
Yes
No
Machine ON/OFF
Quick Plug attached
Presence of Ozone
Ozone Water Flow
Ozone Water Systems 5
*
Ozone Measurement (Air+Surface Sterilizer only)
*
Yes
No
Environment Condition
*
ON/OFF
Air-Conditioning System
ON
OFF
N/A
Fan
ON
OFF
N/A
Exhaust System
ON
OFF
N/A
Equipment Used
*
Ozone Monitor 106-L
Other
Number of Measurement Point
*
1
2
3
4
5
6
7
8
9
10
Ozone Measurement Reading
1st Reading
2nd Reading
3rd Reading
Point 1
Point 2
Point 3
Point 4
Point 5
Point 6
Point 7
Point 8
Point 9
Point 10
Result: Avg ppm Point 1
Result: Avg ppm Point 2
Result: Avg ppm Point 3
Result: Avg ppm Point 4
Result: Avg ppm Point 5
Result: Avg ppm Point 6
Result: Avg ppm Point 7
Result: Avg ppm Point 8
Result: Avg ppm Point 9
Result: Avg ppm Point 10
Ozone Measurement Point
*
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Take photo(s) of each measurement point
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Note:
Ozone monitor measurement scale: 10 ppb (parts per billion) = 0.01 ppm (parts per million).
Summary:Ozone measurements fluctuate up and down due to air movement but the average ozone level at each area is within the international standard set below 0.05 ppm (parts per million) over the 24 hours continuously.Below is a list of standard references:Exposure limit values:OSHA: Permissible Exposure Limit: 8 hour TWA 0.1 ppmANSI/ASTM: 8 hour TWA 0.1 ppm / STEL: 0.3 ppmACGIH: 8 hour TWA 0.1 ppm / STEL 0.3 ppmNIOSH: Exposure Limit Ceiling Value 0.1 ppm (light)/ l 0.08 ppm (moderate) / 0.05 ppm (heavy)
N/A
Remarks
Engineer / Technician Name
*
Please Select
Lim Chang Jin
Muhammad Haziq
Muhammad Badri Hafiz
Date of Commissioning
*
-
Day
-
Month
Year
Date
Engineer's Signature
*
Received in Good Working Condition by
*
Photo of Customer/Name Card
Customer's Signature
*
*By signing above, I certify that I have my company’s authorization to purchase items indicated on this service report on behalf of my company. I hereby authorize Medklinn International Sdn Bhd to perform the work described herein for the prices indicated. This signed service report will be used as a substitute purchase order until Medklinn receives my company’s formal written purchase order.
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