Warewashing Service Form

Distributor: *

Account Info:

Date: *

Time: *

Location:

Manufacturer:

Model:

Detergent Dispenser:

Rinse Injector Sanitizer:

Labor Type:

1. Water hardness gpg.:
2. Detergent concentration:
3. Prewash temp.:
4. Wash temp.:
5. Final rinse temp.:
6. Final rinse pressure lb/in:
7. Flex Hose:
8. Gauges:
9. Curtains/Doors:
10. Leaks:
11. Wash arms & jets:
12. Rinse arms & jets:
13. Bearings:
14. Bypass gal/min:
15. Overflow:
16. Drains/Grease trap:
17. Motors lube and air flow:
18. Pump intake:
19. Conveyor speed:
20. Detergent probe:
21. Procedures:
22. Sanitizer ppm.:

Results

	Items	N/A	Good	Fair	Poor
1	Sanitation
2	Pots/Pans
3	Dishes
4	Glasses
5	Flatware

Action Taken:

Stock

Quantity*	Product*	Packaging*

Customer Email:

Additional Email:

Technician Signature: *	Customer Signature: *
*REQUIRED - I acknowledge that entering my name above acts as my electronic signature
Send Copy to Dennis Joy
Send Copy to Bob St. Martin