Dunkirk PWXL - Initial Operational Boiler Test Check-Out Certificate & Signed Receipt

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INITIAL OPERATIONAL BOILER TEST CHECK-OUT CERTIFICATE & SIGNED RECEIPT
Boiler Manufacturer: Boiler Identifi cation:
Model #: _______________________________________________
Serial #: ________________________________________________
Measured BTUh input: _____________________ Operational Test Date: ________ /________ /_________
Installation Instructions in the Installation, Operation and Maintenance Manual have been followed.•
Initial Operational Boiler Test Check-Out Procedure has been performed.•
Information on this form is certifi ed to be correct.•
All boiler instructions, wiring diagrams, piping diagrams, and supporting information shipped with this •
boiler forwarded to owner/maintenance personnel.
Installation Location:
Customer Name: __________________________________________________________________________
Address: _________________________________________________________________________________
City: ________________________________________________ State: ________ Zip: ___________________
Installer Information
Company/Contractor: ______________________________________________________________________
Address: _________________________________________________________________________________
City: ________________________________________________ State: ________ Zip: ___________________
Telephone #: _____________________________________________________________________________
Installer’s Signature ___________________________________ Date: ________ /________ /_________
Installer’s Printed Name: ___________________________________________