Job Name _________________________________________________________ Check, Test & Start Date ________________City or Town __________________________________________ State _________________________ Zip ________________Who is Performing CTS _____________________________________ Equipment Type (Check all that apply)General Contractor _________________________________________Essential Items Check of System – Note: “No” answers below require notice to installer by memorandum (attached copy.)□Closed Loop □Open Loop□Geothermal □Other (specify)______________Water Source Heat Pump Equipment Check, Test and Start FormEssential Items CheckA. Voltage Check__________ Volts Loop Temp. ___________ °F Heating System Water P.H. Levels __________Set For ___________ °F CoolingB. Yes No Condition Comments□ □ Loop Water Flushed Clean _________________________________________________________________□ □ Closed Type Cooling Tower _________________________________________________________________□ □ Water Flow Rate to Heat Pump Balanced ______________________________________________________□ □ Standby Pump Installed ___________________________________________________________________□ □ System Controls Functioning _______________________________________________________________□ □ Outdoor Portion of Water System Freeze Protected ______________________________________________□ □ Loop System Free of Air ___________________________________________________________________□ □ Filters Clean ____________________________________________________________________________□ □ Condensate Traps Installed _________________________________________________________________Note: “No” answers below require notice to installer by memorandum (attached copy.)□ □ Outdoor Air to Heat Pumps: ________________________________________________________________□ □ Other Conditions Found: ___________________________________________________________________This form must be completed and submitted within ten (10) days of start-up to comply with the terms of the Daikin warranty. Forms shouldbe returned to Daikin Warranty Department.Installation DataPlease include any suggestions or comments for Daikin Applied: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Above System is in Proper Working OrderNote: This form must be filled out and sent to the warranty administratorbefore any service money can be released.DateSignature for Sales RepresentativeSignature for CustomerFor Internal UseRelease:SM ________________________CTS ________________________T ________________________Service Manager ApprovalDateForm WS-CTS-00.01 (Rev. 4/14)IM 447-11 32 www.DaikinApplied.com