Document name: Maintenance & Operational Procedures for the control of Legionella, water hygiene, ‘safe’ hot water, cold water, drinking water and non-drinking water. Document type



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Procedure:

SHOWER HEADS & HOSES CLEAN & DESCALE RECORD SHEET

Frequency:

Quarterly

Acceptance date:

Oct’12

File Ref:

C - LEG41

Next review date:

Oct’14

Property:





System ID:





LOCATION

Mains or tank fed?

Dismantled head, rose & hose?

[Yes or No]

Descaled head, rose & hose?

[Yes or Replaced]

Adjustable spray head

Refit & flushed for 5 minutes?

Initial & Date




MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No







MC/TC

Yes / No

Yes / Replaced

Yes / No

Yes / No




Observation and comments:



I, the undersigned, have completed the works outlined above:

Competent Person


Name:

Signature:


Date:

Authorised Person [Water]


Name:

Signature:

Date:

Additional docket numbers issued:





PPM:

OUTSIDE CONNECTIONS

PPM Ref:

C – LEG08

Frequency:

Annually



The existence of outside connections and their necessity is checked on an annual basis and recorded on form C – LEG08, ensuring that an appropriate back flow prevention device has been installed applicable to the connections usage.


  1. Complete external walk around each building, including any internal quad or garden areas to check the existence of any outside taps.

  2. Where an outlet is found then record the location on form C – LEG08 and complete each of the questions on the form.


RECORD SHEET C – LEG08 MUST BE FILLED IN AND RETURNED TO THE AUTHORISED PERSON [WATER]




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