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INSTALLATION QUALIFICATION PROTOCOL

For the

NEW PURIFIED WATER SYSTEM

Prepared by

____________________________________
TABLE OF CONTENTS
1.0 PURPOSE AND OBJECTIVE(S) .................................................................................................................................... 4
2.0 BACKGROUND .............................................................................................................................................................. 4
3.0 SCOPE ........................................................................................................................................................................... 4
4.0 REFERENCES ............................................................................................................................................................... 4
5.0 RESPONSABILITIES ...................................................................................................................................................... 5
5.1 Validation Specialist ................................................................................................................................................... 5
5.2 Quality Dept. ............................................................................................................................................................... 5
5.3 Facility Dept. ............................................................................................................................................................... 5
6.0 METHODOLOGY............................................................................................................................................................ 6
6.1 Verification Data Sheet ............................................................................................................................................... 6
6.2 Deviation Report ......................................................................................................................................................... 6
6.3 Signature Log Sheet ................................................................................................................................................... 6
6.4 Test Instruments Calibration ....................................................................................................................................... 6
7.0 EQUIPMENT/PROCESS DESCRIPTION ....................................................................................................................... 7
7.1 Water Softener ........................................................................................................................................................... 7
7.2 Ozone Generator ........................................................................................................................................................ 7
7.3 Reverse Osmosis ....................................................................................................................................................... 7
7.4 Mixed Bed................................................................................................................................................................... 7
7.5 Ozone Destructor ....................................................................................................................................................... 7
7.6 De-gasifier .................................................................................................................................................................. 8
7.7 UV light ....................................................................................................................................................................... 8
7.8 Filter ........................................................................................................................................................................... 8
APPENDIX I: DEVIATION REPORT .......................................................................................................................................... 11
APPENDIX II: SIGNATURE IDENTIFICATION LOG SHEET .................................................................................................... 12
APPENDIX III: TESTING INSTRUMENTS LOG SHEET ........................................................................................................... 13
IQ-01 EQUIPMENT VERIFICATION .......................................................................................................................................... 15
IQ-02 DOCUMENT INVENTORY VERIFICATION .................................................................................................................... 37
IQ-03 DRAWING VERIFICATION .............................................................................................................................................. 56
IQ-04 SYSTEM DESIGN VERIFICATION.................................................................................................................................. 58
IQ-05 PLACEMENT VERIFICATION ......................................................................................................................................... 60
IQ-06 UTILITY VERIFICATION .................................................................................................................................................. 67
IQ-07 INSTRUMENTATION VERIFICATION ............................................................................................................................. 86
IQ-08 MAINTENANCE VERIFICATION ..................................................................................................................................... 88
IQ-09 SAFETY & ERGONOMICS VERIFICATION .................................................................................................................. 107
IQ-10 PROCEDURE VERIFICATION ...................................................................................................................................... 109
IQ CHECKLIST VERIFICATION .............................................................................................................................................. 127
REVISION HISTORY

Revision Description of change Date


1.0 PURPOSE AND OBJECTIVE(S)
This protocol (___) intends to provide documented evidence that the new Purified Water System
was installed according to manufacturer’s specifications and ___ ___ requirements.
This Installation Qualification will provide documented evidence that all key aspects of the Purified
Water System equipment’s assembly and its auxiliary systems is as intended by manufacturer
design and in accordance to ___’s requirements.
At the end of the execution activities, a final report will be developed with a summary of the
executed tests results and the recommendation(s) necessary for the Installation Qualification.
Potential risks involved with the new Purified Water System installation when connected to the
manufacturing processes has already being evaluated by Risk Assessment PLS 0410.

2.0 BACKGROUND
In order to meet the new purified water utility demands at ___ I in ___ ___, ___ ___, a new purified
water system was purchased to replace the existing system. It is expected that this new purified
water system will increase the supply to up to 100 GPM. Additionally, it is intended to produce a
water quality that meets or exceeds current Purified Water USP and EP standards.

3.0 SCOPE
This protocol applies to the new equipment and auxiliary components that constitute the Purified
Water System, installed at ___ in ___ ___, ___ ___

4.0 REFERENCES
• FDA’s Office of Regulatory Affairs: “Guide To Inspections of High Purity Water Systems”
5.0 RESPONSABILITIES
5.1 Validation Specialist
• Prepare the documents that are applicable to the Validation exercise
• Coordinate efforts and resources, along with Facilities Dept., to perform the Validation
exercise
• Execute and collect the verification data for the Validation protocol
• Verify data against Acceptance Criteria and initiate deviation, as applicable
• Investigate, justify, and correct any deviation encountered during Validation execution
• Prepare validation Final Report
5.2 Quality Dept.
• Evaluate with the originator the extent of the validation required
• Review and approve documents for the validation exercise
• Review and approve validation activities for compliance and adherence to ___’s policies,
practices, and procedures
• Check that the collected data meets the acceptance criteria and that all the deviations (if
applicable) are properly resolved
• Once executed, review any deviations generated to confirm that investigation and
resolutions are complete
• Cooperate with Validation Specialist to investigate, justify, and correct any deviation
encountered during Validation execution
• Review and approve Final Report
• Maintain original validation documentation, except for drawings and equipment manuals
that will remain in the equipment information files
• Store the Validation Package in a designated filing area
5.3 Facility Dept.
• Review and approve documents for the validation exercise
• Coordinate efforts and resources to perform the validation activities
• Supply documentation and tools needed for the protocol execution
• Provide training in this protocol to all employees involved (internal and external) during the
execution of this protocol and ensure that all signatures are collected on Signature Log
Sheet
• Assist to document, investigate, justify, and correct any deviation encountered during the
IQ protocol execution
• Review and approve validation Final Report
• Provide technical support for trouble shooting during the execution
6.0 METHODOLOGY
6.1 Verification Data Sheet
All data resulting from test execution will be entered in Verification Data Sheets that will pre-
define the objective(s) to be attained with the verification, the procedure that will be followed
to reach such objective(s), the reference material to be used, and the criteria to evaluate as
to accept or not the testing results. All data entry will be properly signed and dated by the
executor in the “Performed By” and “Date” spaces. In cases where a Field Verification is
requested, a “Fail” condition will be applied to unverifiable information.
The comments/observations section included in each Data Collection Form will be used to
describe any additional information considered of importance for describing the validated
condition and/or discrepancies and resolution activities produced during the execution. The
comments/observations included must be signed or initialed and dated.
When the test execution is finished, a subject matter expert will sign and date on the
“Reviewed by” and “Date” spaces respectively, to state the completeness and correctness of
the data.
6.2 Deviation Report
The following deviations must be documented using the Deviation Report Form attached to
this protocol:
• Results invalidated and/or not in compliance with their pre-established Acceptance Criteria
• Testing procedure and/or sampling plan not followed or that could not be completed as
planned
These deviations will be handled as per ___ ___ PR
The investigation process due to deviated sampling results will be handled by contract
laboratory, following their own investigation procedures. These incidents will be informed to
who oversees the validation project in ___ ___, ___ PR, which in turn will open a deviation
report to follow the lifecycle of the investigation and to implement any possible changes due
to investigation resolution.
Typographic, text edit and syntax errors will be documented as such in the “Comments”
section under the corresponding test script, and considered as a minor issue that may not
invalidate a test or become cause for writing a deviation report. These will be explained in the
Final Report.
6.3 Signature Log Sheet
Each individual who signs or initials any page included in this protocol shall be identified
using the Signature Log Sheet by type/printed name, full signature, written initials and
department represented.
6.4 Test Instruments Calibration
All testing equipment used during for the execution shall be currently calibrated with
documented evidence of its “up to date” calibration status. Copies of the calibration
certificates shall be attached to the protocol and referred to the applicable test script.
7.0 EQUIPMENT/PROCESS DESCRIPTION
Purified Water▲ is water obtained by distillation, ion-exchange treatment, reverse osmosis, and
other suitable processes. It is prepared from water complying with the regulations of U.S.
Environmental Protection Agency (EPA) with respect to drinking water. It contains no added
substances.
The Purified Water system includes the following equipment, along with associated components:

• 30 um filters (2) • 6, 000 and 8, 000 Gal. Tanks


• 1 um filters (4) • Distribution Pumps (4)
• 0.2 um filters (4) • Dual Reverse Osmosis unit
• Dual Softener unit • Dual Mix Bed unit
• Ozone Generator • UV lamps (4)
• Ozone Destructor • Degasification unit
• Microza filters (18)

7.1 Water Softener


The Water Softener reduces the levels of calcium and other scale creating elements from the
process stream. Water softeners also remove aluminum, copper and other trace metals. The
removal process occurs by ion exchange. The softener vessel is filled with sodium form cation
resin. The calcium, magnesium, barium, strontium, and other ions removed by the resin are
replaced with sodium ions. The cation resin has a fixed capacity for ion removal and must be
regenerated when that capacity has been exhausted.
7.2 Ozone Generator
The Ozone Generator is employed to produce the Ozone used to sanitize the Softened Water
that passes through to the 6,000 Gallon Tank.
7.3 Reverse Osmosis
The Reverse Osmosis unit processes water by means of semi-permeable membranes, which
allow pressurized water to freely pass through the membranes, but almost totally reject
dissolved and suspended substances in the feed water.
7.4 Mixed Bed
The Mixed Bed de-mineralizes water by using the ion exchange process. The influent water
passes through a bed of Cation and Anion resin that are intimately mixed. The mixed bed
configuration functions similarly to a two-bed configuration in regards to the ion exchange
process; however, it is much more efficient and therefore produces water of much greater
purity.
7.5 Ozone Destructor
The Ozone Destructor employs ultraviolet light to reduce the ozone level to a safe preset level
before exiting the skid to the Service Points of Use. Ozone reduction is done by breakage of
the O3 bonds at the ultraviolet spectrum.

As per United States Pharmacopeia (USP) standards
7.6 De-gasifier
De-gasifier membranes are employed to reduce the oxygen level of the water. Membrane
contactors make it possible to transfer gas from an aqueous stream without dispersion. By
virtue of surface tension, the water on one side of the membrane is exposed to the gas side of
the membrane with no liquid transfer, providing a large surface area for gas/liquid contact and
transfer. Dissolved O2 passes from the water surface into the gas side by diffusion and is
swept out by a combined vacuum/air flow.
7.7 UV lights
Ultraviolet lamps produce UV-C (germicidal UV), which is a radiation that when harmful
microbes are exposed to the UV rays, scrambles the DNA structure of the organism,
rendering it sterile and can no longer reproduce.
Almost all of a UV lamp’s output is concentrated in the 254 nanometers (nm) region in order to
take full advantage of the germicidal properties of this wavelength. The lamp is mounted such
that water passing through a flow chamber is exposed to the UV-C light rays.
7.8 Filters
At the first stage, the raw water enters a 30 µm pre-filter to trap any heavy sediment before it
enters the softeners. The 1 µm filters will act as a resin trap and removes suspended from the
softeners. The absolute 0.2 micron rated filters significantly enhances the water quality with its
capacity to remove the majority of microorganisms. The Microza ultra filters that are at the end
of the purified water system uses fiber hollow technology that will remove endotoxins and
viruses.
7.9 Distribution Pumps
Two pairs of distribution pumps will provide constant flow of the processed water throughout
the Purified Water System pipelines. Although its functionality will not contribute directly to the
processing of Purified Water, by providing a constant flow will indeed significantly reduce the
chances of microbial growth due to stagnant water.
7.10 Tanks
Two storage tanks will provide storage capacity to the Purified Water System. A 6,000 gallon
tank will store ozone-treated softened water that will supply constant feed to the dual R.O.
unit, while an 8,000 gallon tank will store water post reverse osmosis and de-ozonization
treatment, which will supply constant feed to the main loop.
With this configuration in place, a Purified Water (USP, EP) quality is intended to be achieved through the following processes:
• Filtration (by means of 30 um filters, 1 um filters, 0.2 um filters, and R.O. Unit, and “Microza” filters)
• Ion exchange (by means of Softener and Mix Bed)
• Sanitation (by means of Ozone Injection and UV light radiation)
• Degasification (by means of a de-gasifier unit)
APPENDICES
DEVIATION DESCRIPTION

APPENDIX I: DEVIATION REPORT

Deviation Number: _________________


Test Description/Test Number:
Deviation Area: □ I/Q □ O/Q □ P/Q

Deviation reported by:_________________________________ Date: _________________

ENGINEERING INVESTIGATION

Attach additional pages, if necessary

Root Cause: □Manpower □Methods □Equipment □ Materials □Environment

CORRECTIVE / PREVENTIVE ACTION

Evaluation performed by:____________________________________ Date: _________________

Testing required after Corrective action implemented? (YES/NO) ______________

Test results (PASS/FAIL/NA) ________________

Performed by: _______________________________________ Date: _______________________

Comments:

Reviewed by ______________________________________ Date: ____________________________


APPENDIX II: SIGNATURE IDENTIFICATION LOG SHEET

This sheet is intended to record each individual who takes part of the execution process and is not
included in the front page. The scope of this sheet applies to anyone who signs or initials any page
included in the attached qualification documents. Each person shall be identified by typed or printed
name, full signature, written initials, and department represented.

NAME SIGNATURE INITIALS DEPARTMENT


APPENDIX III: TESTING INSTRUMENTS LOG SHEET

This sheet is intended to record all field test instrument that assists in the execution process.

COPY OF
CALIBRATION CERTIFICATE PERFORMED
INSTRUMENT ID DESCRIPTION TEST ID
DATE/DUE DATE ATTACHED? BY/DATE
(YES/NO)
VERIFICATION DATA SHEETS
INSTALLATION QUALIFICATION
MAIN COMPONENT VERIFICATION IQ-01
Objective:

• Assure that all main and auxiliary components of the Purified Water System are as per
manufacturer/vendor specifications (Manuals, Spec sheets, P & ID’s, etc.)
Procedure:
a. Per equipment, collect and document the required information thru physical inspection (tag,
engrave, plate, sticker, etc)
b. Evaluate findings against specifications
References Required:

• Note: Vendor/Manufacturer documentation (Manuals, Spec sheets, P & ID’s, etc.) does not
count as “Actual Result” reference
Acceptance Criteria:

• Actual results match expected results as per manufacturer written specifications


MAIN COMPONENT VERIFICATION IQ-01
Filter set 1A & 1B

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID
Cartridge
Manufacturer
Cartridge Part
No.
1A

Housing
Manufacturer
Housing
Part No.
Quantity

Tag ID

Cartridge
Manufacturer
Cartridge Part
No.
1B

Housing
Manufacturer
Housing
Part No.

Quantity

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Filter set 2A & 2B

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID
Cartridge
Manufacturer
Cartridge Part
No.
2A

Housing
Manufacturer
Housing
Part No.
Quantity

Tag ID

Cartridge
Manufacturer
Cartridge Part
No.
2B

Housing
Manufacturer
Housing
Part No.

Quantity

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Filter set 3A & 3B

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID
Cartridge
Manufacturer
Cartridge Part
No.
3A

Housing
Manufacturer
Housing
Part No.
Quantity

Tag ID

Cartridge
Manufacturer
Cartridge Part
No.
3B

Housing
Manufacturer
Housing
Part No.

Quantity

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Filter set 4A & 4B

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Cartridge
Manufacturer

Cartridge Part
No.
4A

Housing
Manufacturer
Housing
Part No.
Quantity

Tag ID

Cartridge
Manufacturer
Cartridge Part
No.
4B

Housing
Manufacturer
Housing
Part No.

Quantity

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Filter set 5A & 5 B

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Cartridge
Manufacturer

Cartridge Part
No.
5A

Housing
Manufacturer
Housing
Part No.
Quantity

Tag ID

Cartridge
Manufacturer
Cartridge Part
No.
5B

Housing
Manufacturer
Housing
Part No.

Quantity

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Ozone Generator

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Tag ID
Booster pump

Manufacturer

Model

Serial No.

Tag ID
Recirculation pump

Manufacturer

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Ozone Destructor

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Tag ID

Manufacturer
UV light

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Dual Softener unit

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer
Unit A

Model

Serial No.

Tag ID

Manufacturer
Unit B

Model

Serial No.

Manufacturer
Control Panel

Model
Resin

Type

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Dual Softener unit (Brine Tank)

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
6,000 Gal. Tank

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Description

Cartridge
Manufacturer

Cartridge
Vent Filter

Part No.

Housing
Manufacturer

Housing
Part No.

Manufacturer
Level

Part No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Distribution Pumps (1A, 1B)

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer
1A

Model

Serial No.

Tag ID

Manufacturer
2A

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
8,000 Gal. Tank

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Description

Cartridge
Manufacturer

Cartridge
Vent Filter

Part No.

Housing
Manufacturer

Housing
Part No.

Manufacturer
Level

Part No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Distribution Pumps (2A, 2B)

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer
2A

Model

Serial No.

Tag ID

Manufacturer
2B

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
UV lamps (1A, 1B)

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer
1A

Model

Serial No.

Tag ID

Manufacturer
1B

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


EQUIPMENT VERIFICATION IQ-01
UV lamps (2A, 2B)

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer
2A

Model

Serial No.

Tag ID

Manufacturer
2B

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01

Dual Reverse Osmosis (Service unit A)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Tag ID
Feed Pump

Manufacturer

Model

Serial No.
Antiscalant Dosing System

Tag ID

Manufacturer

Model

Serial No.
Control Panel

Manufacturer

Model

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Dual Reverse Osmosis (Service unit B)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Tag ID
Feed Pump

Manufacturer

Model

Serial No.
Antiscalant Dosing System

Tag ID

Manufacturer

Model

Serial No.
Control Panel

Manufacturer

Model

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Dual R.O. unit (Cleaning Skid)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Tag ID
Cleaning Pump

Manufacturer

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
De-gasification unit

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Model

Serial No.

Tag ID

Manufacturer
Pump

Model

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Dual Mixed Bed unit

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer
Unit A

Model

Serial No.

Tag ID

Manufacturer
Unit B

Model

Serial No.

Manufacturer
Control Panel

Model
Caustic
Acid &

Type

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAIN COMPONENT VERIFICATION IQ-01
Microza “ultra filtration” filters

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Tag ID

Manufacturer

Part No.

Serial No.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Objective:

• Assure that all the basic literature required for the system operation/maintenance of the Purified
Water system is available and properly stored
Procedure:
a. Per equipment, collect all related documentation
b. Document all relevant information according to “Document Info” column
c. If any of the “document type” is not applicable, write an Not Apply to the “Document Info”
column and explain in the “Comments/Observations” section
References Required:

• Manufacturer’s Documentation - Installation and Operational Manuals, Wiring Diagrams, Spare


Parts List, P & ID’s, etc.

• Vendor’s Documentation - Purchase Order, etc.


Acceptance Criteria:

• At least the basic literature (see document type) was found for all equipment and was found to
be properly stored

• “Not applicable” document type was properly explained


DOCUMENT INVENTORY VERIFICATION IQ-02
Filter set 1A & 1B

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Filter set 2A & 2B

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Filter set 3A & 3B

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Filter set 3A & 3B

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:

DOCUMENT INVENTORY VERIFICATION IQ-02


Filter set 4A & 4B

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:

DOCUMENT INVENTORY VERIFICATION IQ-02


Filter set 5A & 5B

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Dual Softener unit

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE
Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

Mechanical
Drawings

P & ID’s

PLC Software
Backup &
Report

MSDS

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
6,000 Gal. Tank

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Distribution Pumps (1A, 1B)

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

Mechanical
Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
8,000 Gal. Tank

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Distribution Pumps (2A, 2B)

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

Mechanical
Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Ozone Generator

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

Mechanical
Drawings

P & ID’s

PLC Software
Backup &
Report

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Ozone Destructor

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

P & ID’s

PLC Software
Backup &
Report

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
UV lamps (1A, 1B, 2A, 2B)

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Dual Reverse Osmosis unit

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE
Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

Mechanical
Drawing

P & ID’s

PLC Software
Backup &
Report

MSDS

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Degasification unit

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

Mechanical
Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Dual Mixed Bed unit

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

P & ID’s

PLC Software
Backup &
Report

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DOCUMENT INVENTORY VERIFICATION IQ-02
Microza “ultra filtration” filters

DOCUMENT DOCUMENT INFO DOCUMENT STORAGE PERFORMED


TYPE (DOC #, TITLE, REV., LOCATION) (LOCATION) BY/DATE

Installation and
Operation
Manual

Purchase Order

Electrical
Drawings

P & ID’s

Other
Documents

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) ________ If NO, refer to Deviation # __________

Reviewed by: Date:


DRAWING VERIFICATION IQ-03
Objective:

• Assure concordance between drawings (P & I D’s and Electrical Schematics, etc.) and field
installation of the Purified Water System
Procedure:
a. Collect and document the drawings found thru IQ - 02: “Document Inventory Verification”
b. Verify against field installation by performing a physical inspection and redline drawings, if
discrepancy occurs
c. Sign, date & submit discrepancies to Facilities Dept. for review
d. Upon review, determine if drawings and/or field installation needs to be updated
e. Attach verified drawings to this protocol
References Required:

• Process and Instrument Diagrams (P & I D’s)

• Electrical Schematics
Acceptance Criteria:

• Drawings match field installation and vice versa

• Discrepancies between drawings and field installation were satisfactorily resolved by submitting
changes and updating drawings and/or field installation
DRAWING VERIFICATION IQ-03
Sheet ______ of ______
Use additional pages as necessary
DRAWING REDLINED? UPDATE? PERFORMED
TITLE & REVISION
TYPE & ID (YES/NO) (DWG, FLD, NA) BY/DATE

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


SYSTEM DESIGN VERIFICATION IQ-04
Objective:

• Assure that the installation design is in compliance with the specified requirements for systems
capable of producing Purified Water
Procedure:

• Verify system installation as per specifications by performing a physical verification and/or


providing documented evidence

• Document findings and evaluate against expected results


Note: This verification is best performed during “Drawing Verification”
References Required:

• P & ID’s
• Material Safety Data Sheets
• Chemical Analysis Sheets
Acceptance Criteria:

• Actual results match expected results as per Purified Water specifications


SYSTEM DESIGN VERIFICATION IQ-04

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The raw water source supplied to


Feed water the system must be from Well or
City Water

The system contains equipment


capable of performing Deionization
Processing and Reverse Osmosis or
Distillation.

Piping will provide constant


circulation of Purified water.

Piping does not have an unused


Piping portion greater in length than six
diameters of the unused pipe
measured from the axis of the pipe
in use (dead leg).

Contact All material in direct contact shall be


material non-reactive to Purified Water.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
Objective:

• Assure that the equipments have the appropriate conditions to perform setup and maintenance
and to operate accordingly.
Procedure:

• Per equipment, verify field conditions by performing a physical inspection as per expected
results

• Document and evaluate findings against expected results


References Required:

• Skid Drawings
Acceptance Criteria:

• Actual results match expected results as per ___ requirements


PLACEMENT VERIFICATION IQ-05
SKID #1 - Filter Set 1A, 1B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
SKID #2 - Filter set 2A, 2B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
SKID #3 - Distribution Pumps 1A, 1B; UV lamps 1A, 1B & Filter set 3A, 3B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
SKID #4 - R. O. Piping/Valves

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
SKID 5 - Pumps 2A, 2B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
SKID 6 - UV lamps 2A, 2B & Filter 4A, 4B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
SKID 7 - Filter set 5A, 5B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

PLACEMENT VERIFICATION IQ-05


Water Softener Skid

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

PLACEMENT VERIFICATION IQ-05


Ozone Generator Skid

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PLACEMENT VERIFICATION IQ-05
Ozone Destructor Skid

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

PLACEMENT VERIFICATION IQ-05


R.O. Skid

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

PLACEMENT VERIFICATION IQ-05


R.O. Cleaning Skid

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

The equipment shall


Position be located along open
type waste drains.

The equipment is not


placed on direct
Environment sunlight or other
sources of heat.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

UTILITY VERIFICATION IQ-06


Objective:
• Assure that the installed utility meets the Purified Water System requirements
Procedure:

• Utility Verification

a. Per equipment, perform utility verification as per expected results by using a calibrated test
instrument (when required), and document results
b. Attach copy of instrument calibration certificate and ensure it is up to date
c. Ensure that each utility connection is properly labeled

• Electrical Verification

a. Perform verification as per Utility Verification thru a certified electrician


b. Attach copy of Electrician’s license and ensure it is up to date
Note: All readings will apply a ±10% tolerance
References Required:

• Test Instruments calibration certificates

• Copy of Electrician’s license


Acceptance Criteria:

• Utilities comply with expected results (manufacturer specifications)

• All calibrations/certifications are up to date


UTILITY VERIFICATION IQ-06
Dual Softener unit

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID

To be filled by a licensed electrician or electrical engineer with PE license


Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: ____________________________

PERFORMED
OTHER SPECS EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

Compressed Air

Chemical

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Ozone Generator

ELECTRICAL EXPECTED PERFORMED


ACTUAL RESULT PASS/FAIL
SPECS RESULT BY/DATE
Voltage
Phase
OZ-1

Amperage
Frequency
Panel ID
Voltage
Phase
P-OZ1

Amperage
Frequency
Panel ID
Voltage
Phase
P-OZ2

Amperage
Frequency
Panel ID
Voltage
Transformer

Phase
Amperage
Frequency
Panel ID
To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ___________________________ License Number: ___________________________


EXPECTED PERFORMED
OTHER SPECS ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Compressed Air 90-110 psig


Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Ozone Destructor

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID

Bulb installation

To be filled by a licensed electrician or electrical engineer with PE license


Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: ____________________________

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
UV lamps (1A, 1B)

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID

Bulb installation

To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: ____________________________


Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
UV lamps (2A, 2B)

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID

Bulb installation

To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: ___________________________

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Distribution Pumps (1A, 1B)

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID

To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: ___________________________


Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Distribution Pumps (2A, 2B)

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID

To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: ___________________________


Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Dual Reverse Osmosis unit

ELECTRICAL EXPECTED PERFORMED


ACTUAL RESULT PASS/FAIL
SPECS RESULT BY/DATE
1
Voltage
2
Voltage
1
Phase
2
Unit A

Phase
1
Amperage
2
Amperage
Frequency
Panel ID
1
Voltage
2
Voltage
1
Phase
Unit B

2
Phase
1
Amperage
2
Amperage
Frequency
Panel ID
To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: _____________________________


PERFORMED
OTHER SPECS EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

Compressed Air 80-110 psig


1
Comments/Observations: Assembly power to assembly panel (PLC)
2
Plant power to assembly power

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Dual Reverse Osmosis unit (Cleaning Skid)

ELECTRICAL PERFORME
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS D BY/DATE
Voltage

Phase

Amperage

Frequency

Panel ID
To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ____________________________ License Number: _________________________


PERFORME
OTHER SPECS EXPECTED RESULT ACTUAL RESULT PASS/FAIL
D BY/DATE

Chemicals
Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Dual Reverse Osmosis unit (pumps)

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE
Voltage
R.O Feed Pump

Phase

Amperage

Frequency

Panel ID

Voltage
R.O. Cleaning

Phase
Pump

Amperage

Frequency

Panel ID

Voltage
ADS Pump

Phase

Amperage

Frequency

Panel ID

To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________


Electrician signature: ____________________________ License Number: ____________________________
Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

UTILITY VERIFICATION IQ-06


Degasification unit

ELECTRICAL EXPECTED PERFORMED


ACTUAL RESULT PASS/FAIL
SPECS RESULT BY/DATE

Voltage
Degas Panel

Phase

Amperage

Frequency

Panel ID

Voltage
Vacuum Pump

Phase

Amperage

Frequency

Panel ID

To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________


Electrician signature: ___________________________ License Number: _____________________________
EXPECTED PERFORMED
OTHER SPECS ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

Compressed Air
Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


UTILITY VERIFICATION IQ-06
Dual Mixed Bed unit

ELECTRICAL PERFORMED
EXPECTED RESULT ACTUAL RESULT PASS/FAIL
SPECS BY/DATE

Voltage

Phase

Amperage

Frequency

Panel ID
To be filled by a licensed electrician or electrical engineer with PE license

Does electrical installation comply with NEC standards? (YES/NO) _______________

Electrician signature: ___________________________ License Number: ____________________________


PERFORMED
OTHER SPECS EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE
Compressed Air
(control panel)
Clean Compressed
Air
(MB column)

Chemicals

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


INSTRUMENTATION VERIFICATION IQ-07
Objective:

• Assure that all the instrumentation installed in the Purified Water System that requires
calibration are added to a calibration program
Procedure:
a. Inspect all instruments evaluated with the “Calibration Program Addition Form” and verify that all
instruments installed at the Purified Water System were included
b. Record instruments (ID & type) that requires calibration according to the “Calibration Program
Addition Form”
c. Verify if the instrument that requires calibration is currently calibrated and record finding
d. Attach calibration certificate of all calibrated instruments
References Required:

Acceptance Criteria:

• Instruments that required calibration were included in site calibration program

• Instruments are currently calibrated


INSTRUMENTATION VERIFICATION IQ-07
Sheet ______ of ______
Use additional pages as necessary

IT IS CURRENTLY
INSTRUMENT CALIBRATION PERFORMED
INSTRUMENT ID CALIBRATED?
TYPE DUE DATE BY/DATE
(YES/NO/NA)

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Objective:

• Assure that the Purified Water System is included in a Preventive Maintenance Program and a
spare parts list exists
Procedure:
a. Per equipment, verify and document the required information by collecting documented
evidence (i.e. PM checklist, PM schedule) of the inclusion of the Purified Water System
components into ___’s Preventive Maintenance Program
b. Collect the Spare Parts list; verify & document the required information
c. Collect the Lubricants list; verify & document the required information
d. If lubricant specifications is not applicable, write a Not Apply to the “Actual Result” column and
explain in the “Comments/Observations” section
References Required:

• Evidence of PMP inclusion - PM checklist, PM schedule, PM program printouts, etc.

• Spare Parts list

• Lubricants list

• FOP 4.1 “Scheduled Preventive Maintenance”


Acceptance Criteria:

• All equipment is included in a PM schedule

• All equipment has spare part list

• “Not applicable” lubricant requirements were properly explained


MAINTENANCE VERIFICATION IQ-08
Filter set 1A &1B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Filter set 2A & 2B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Filter set 3A & 3B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Filter set 4A & 4B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Filter set 5A & 5B

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Dual Softener unit

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Ozone Generator

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Ozone Destructor

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
6,000 Gal. Tank

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
8,000 Gal. Tank

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Distribution Pumps (1A, 1B)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

MAINTENANCE VERIFICATION IQ-08


Distribution Pumps (2A, 2B)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

MAINTENANCE VERIFICATION IQ-08


UV lamps (1A, 1B)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
UV lamps (2A, 2B)

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Dual Reverse Osmosis unit

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
De-gasification unit

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Dual Mixed Bed unit

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


MAINTENANCE VERIFICATION IQ-08
Microza “ultra filtration” filters

PERFORMED
SPEC EXPECTED RESULT ACTUAL RESULT PASS/FAIL
BY/DATE

A PM checklist,
schedule or similar is
PMP available as evidence
of inclusion into the
PM program.

Spare parts inventory


Spare
is available for the
Parts
equipment.

Lubricants inventory is
Lubricants available for the
equipment.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


SAFETY & ERGONOMICS VERIFICATION IQ-09
Objective:

• Assure that the Purified Water System complies with ___’s EHS Safety and Ergonomics
requirements
Procedure:

• Collect documented evidence (i.e. EHS checklist) of EHS evaluation of the Purified Water
System

• Document evaluation results and compare against expected results


References Required:

• Evidence of EHS evaluation - EHS checklist, etc.


Acceptance Criteria:

• EHS checklist is approved by EHS representative


SAFETY & ERGONOMICS VERIFICATION IQ-09

EXPECTED PERFORMED
SPEC ACTUAL RESULT PASS/FAIL
RESULT BY/DATE

EHS Change
Management
AWO column
checklist was
completed and
approved.
PWS Safety &
Ergonomics
Compliance

EHS found
Purified Water
System to be in
compliance.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Objective:

• Assure written procedures for the operation and maintenance of the Purified Water System
Procedure:
a. Per equipment, collect and evaluate written procedures (i.e. operating, maintenance, cleaning)
and document findings
b. If any of the specifications is not applicable, write a Not Apply to the “Actual Result” column and
explain in the “Comments/Observations” section

c. Evaluate findings against expected results


References Required:

• SOP’s (at least in DRAFT form)


Acceptance Criteria:

• Draft procedures are available for each main component of the Purified Water System.
PROCEDURE VERIFICATION IQ-10
Filter set 1A & 1B

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Filter 2A & 2B

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Filter set 3A & 3B

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Filter set 4A & 4B

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Filter set 5A & 5B

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Dual Softener unit

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Ozone Generator

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Ozone Destructor

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Distribution Pumps (1A, 1B)

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Distribution Pumps (2A, 2B)

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
8,000 Gal. Tank

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
6,000 Gal. Tank

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
UV lamps (1A, 1B, 2A, 2B)

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Dual Reverse Osmosis unit

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10
Degasification unit

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:

PROCEDURE VERIFICATION IQ-10


Dual Mixed Bed unit

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


PROCEDURE VERIFICATION IQ-10

Microza “ultra filtration” filters

EXPECTED ACTUAL RESULT PERFORMED


SOP PASS/FAIL
RESULT (DOC. NO., REV. NO., TITLE, STATUS) BY/DATE

A procedure
Operating
exists at least in
Procedure
Draft form.

A procedure
Maintenance
exists at least in
Procedure
Draft form.

Comments/Observations:

Conformance to the acceptance criteria was evaluated and the final determination is as follows:
Acceptance Criteria met? (YES/NO) __________ If NO, refer to Deviation # __________

Reviewed by: Date:


IQ CHECKLIST VERIFICATION

Verify each of the respective IQ tests and document completion and status.

ACCEPTANCE
TEST DEVIATION DEVIATION
TEST CRITERIA
TEST TITLE EXECUTED NUMBER SOLVED
NUMBER MET?
(YES/NO) (if applies) (YES/NO)
(YES/NO)

IQ-01 EQUIPMENT VERIFICATION

DOCUMENT INVENTORY
IQ-02
VERIFICATION

IQ-03 DRAWING VERIFICATION

IQ-04 SYSTEM DESIGN VERIFICATION

IQ-05 PLACEMENT VERIFICATION

IQ-06 UTILITY VERIFICATION

IQ-07 INSTRUMENTATION VERIFICATION

IQ-08 MAINTENANCE VERIFICATION

SAFETY AND ERGONOMICS


IQ-09
VERIFICATION

IQ-10 PROCEDURE VERIFICATION

Performed by: Date: