Site Description
Customer Name Contact Person ________________________________________
Location ________________________________________________ Nature of Building _____________________________________
Machine / Equipment Description
Machine / Equipment Name Equipment Code
Model No. Serial No.
Installed Location Installed By
Start up date In Warranty Yes No
Failure / Damage Description
Fail Date Time
Hour of Operation Hrs. Number of Start
Sequence of Events
Date Time Occurrence Noticed / Performed by
Last Servicing Date
Last Servicing Performed
Investigation / Observations / Actions Taken
Date of Site Visit Time
Review of Operating Logs
Observation / Inspection Taken
Preliminary Diagnosis
Recommendations
Report By. Attachments Log Sketches Drawings
Signature __________________________ Material Samples Picture
Date _______________________________ Other __________________
Problems Analysis
Analysed By
Signature _____________________________________________
Position _____________________________________________
Date _________________________________________________
Attachment