Summary
Plumbing • Drainage • Electrical • Ventilation • Water Quality
Purpose:
This inspection verifies that all site utilities meet manufacturer, code, and warranty requirements prior to ice machine delivery and installation. Failure to complete this form accurately may result in installation delays, inspection failure, flooding, electrical rework, or denied warranty claims.
Project & Site Information
- Facility Name: __________________________________________
- Department / Room Name: ________________________________
- Physical Install Address: _______________________________
- City / State / Zip: _____________________________________
- Contact Name On-Site: _________________________________
- Phone / Email: ________________________________________
- Ice Machine Manufacturer: _____________________________
- Model Number: ________________________________________
- Ice Type: ☐ Full Cube ☐ Half Cube ☐ Nugget ☐ Flake ☐ Combination
- Estimated Production (lbs/day): _______________________
- Bin Type / Size: ______________________________________
- Target Install Date: _________________________________
Drainage Inspection (CRITICAL PASS/FAIL CATEGORY)
☐ PASS ☐ FAIL
(All items below must pass before installation can proceed)
☐ Gravity drain is present at the install location
☐ Drain outlet elevation is lower than machine drain outlet
☐ Drain line has continuous slope with no backfall
☐ Drain line is properly supported and vented
☐ Drain is not connected to grease waste
☐ Drain is clean and unobstructed
☐ Approved air gap visible at termination
☐ If gravity drain is not available:
- ☐ Drain pump required
- ☐ Drain pump specified and approved
- ☐ Emergency overflow path identified
Inspector Notes (Drainage):
Air Gap & Backflow Prevention (Code & Infection Control)
☐ PASS ☐ FAIL
☐ Approved air gap installed
☐ Backflow prevention device installed where required
☐ Device accessible for inspection and testing
☐ Local plumbing code compliance verified
☐ Healthcare/VA infection control requirements reviewed
Inspector Notes (Air Gap / Backflow):
Ventilation & Heat Rejection
☐ PASS ☐ FAIL
☐ Manufacturer clearance requirements met on all sides
☐ Exhaust air will not recirculate into intake air path
☐ Room temperature within operating range
☐ Mechanical ventilation operating and verified
☐ If space is heat-restricted:
- ☐ Remote condenser specified
- ☐ Water-cooled system approved
- ☐ Equipment enclosure ventilation engineered
Inspector Notes (Ventilation):
Electrical Service Verification
☐ PASS ☐ FAIL
☐ Voltage at site matches manufacturer nameplate: __________
☐ Phase verified: ☐ Single-Phase ☐ Three-Phase
☐ Dedicated circuit provided
☐ Breaker size matches manufacturer specification
☐ Disconnect switch installed and labeled
☐ GFCI protection installed where required
☐ Electrical permit pulled (if required by AHJ)
Inspector Notes (Electrical):
Water Supply & Pressure Testing
☐ PASS ☐ FAIL
☐ Potable cold water supply present at machine location
☐ Static incoming pressure measured: __________ PSI
☐ Pressure within manufacturer operating range
☐ Pressure regulator installed if required
☐ Shutoff valve installed at machine
☐ Supply line flushed prior to hookup
☐ No cross-connection risks identified
Inspector Notes (Water Pressure):
Water Quality & Filtration Verification (Warranty Protection)
☐ PASS ☐ FAIL
☐ Water hardness tested: __________ gpg
☐ Water source: ☐ Municipal ☐ Well ☐ Blended
☐ Filtration type installed:
- ☐ Carbon filtration
- ☐ Carbon + scale inhibitor
- ☐ RO + blending
☐ Filtration sized to machine’s rated production capacity
☐ Filtration cartridges installed and activated
☐ Maintenance responsibility assigned
☐ Cartridge change schedule documented
Inspector Notes (Filtration):
Floor, Access & Structural Conditions
☐ PASS ☐ FAIL
☐ Floor is level and structurally adequate
☐ Floor rated for full machine + bin + ice load
☐ Path of travel clear for equipment delivery
☐ No stairs without rigging plan
☐ Casters / legs installed correctly
☐ Anchoring requirements reviewed if applicable
Inspector Notes (Structural):
Sanitation Access & Inspection Readiness
☐ PASS ☐ FAIL
☐ Rear and side clearances allow proper cleaning
☐ Bin interior fully accessible
☐ Cleaning chemicals staged
☐ Sanitation SOP assigned
☐ Inspection access confirmed
Inspector Notes (Sanitation):
FINAL PRE-INSTALL DETERMINATION
☐ SITE APPROVED FOR INSTALLATION
☐ SITE NOT APPROVED — CORRECTIONS REQUIRED
Deficiencies Requiring Correction:
Inspector Certification
I certify that all information recorded on this inspection form is accurate and reflects current site conditions.
- Inspector Name: _____________________________________
- Company: ___________________________________________
- Signature: __________________________________________
- Date: ______________________________________________
INSTALLATION HOLD NOTICE
Ice machine installation must not proceed if any critical category above is marked FAIL.
Proceeding without correction exposes all parties to:
- Flooding damage
- Electrical rework
- Failed inspection
- Restart service charges
- Denied warranty claims
