INSPECTION FORM Page 1 of 2

MOLDED CASE CIRCUIT BREAKER, < 1000V ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Location: Panelboard/MCC: Cell #:

Breaker Data

Manufacturer: Type: Serial #:

Rated Voltage: V Frame Size: A Trip Unit:

Interrupting Rating: kA Comments:

Breaker Identification Tag Installed: Yes No Visual Signs of Overheating: Yes No

Visual Inspection /

Cleanliness (As Found): Good Acceptable Poor Cables Supported Appropriately: Yes No

Electro/Mechanical
Cleaning

Connections: Good Acceptable Poor N/A Good Acceptable Poor

Interlock:

Ground Connection: Good Acceptable Poor Exercise Circuit Breaker: Yes

Door Mechanical: Good Acceptable Poor Other:

Comments:

Trip Unit Rating: A Trip Unit Type: None Thermal Magnetic Electronic LI LSI LSIG
2
Breaker Settings

Breaker Setting (As Left) Range Setpoint Delay IT

Long Time Fixed Adj. - X A = A sec On Off

Short Time Fixed Adj. - X A = A sec On Off

Instantaneous Fixed Adj. - X A = A N/A

Ground Fault Fixed Adj. - A sec On Off

Perform insulation resistance measurements for breakers >= 250A, or as specified.

Insulation Resistance Test

o Source: Disconnected Connected (Source Isolated) Approval is required, prior to leaving

Temperature: C
Load: Disconnected Connected (Load Isolated) cables connected during the test.

Test Insulation Resistance (MΩ)

Voltage Phase To GND (Breaker Closed) Phase To Phase (Breaker Closed) Line to Load (Breaker Open)
(VDC)
A B C A–B B–C A-C A B C

Test Summary Test Passed Test Inconclusive. Further Investigation Required. Test Failed

Comments:

Perform contact measurements for breakers >= 250A, or as specified.

Resistance

A B C Test Summary
Contact

Resistance (µΩ) Test Passed

Test Inconclusive
Further Investigation Required.
Comments: Test Failed

Form F-BKR-MC-LV Rev 02, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Electrical\Forms\F-BKR-MC-LV.doc
 INSPECTION FORM Page 2 of 2
MOLDED CASE CIRCUIT BREAKER, < 1000V ID:

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection Required: Yes No

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person(s) performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and
that the analysis results are correct.

Form F-BKR-MC-LV Rev 02, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Electrical\Forms\F-BKR-MC-LV.doc
 INSPECTION FORM Page 1 of 3
POWER CABLE, 4160V Cable ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Source: Dest. / Load:

Manufacturer: Type: Conductor: Copper Aluminum

Cable Data

No. of AWG Measured Previous Data

Size: Length: m
Conductors: MCM Jacket Markings TDR
Operating
Rated Voltage: V V Date Installed:
Voltage:
Cable Tray EMT Alum. Conduit Direct Buried
Installation: Other:
Strapped Steel Conduit PVC Conduit Underground Duct

Physical Damage on Exposed Ends: Yes No Cable Identification Tag Installed: Yes No
Inspection

Visual Signs of Overheating/Corona: Yes No Cable Supported Appropriately: Yes No

Visual

Damage to Splices/Terminations: Yes No Shield Grounded: Yes No

Bend Radius Acceptable: Yes No Comments:

Source: Cable Dest. / Load: Note: Approval of City’s Representative

Test
Disconnected Disconnected is required, prior to leaving cables
Preparation:
Connected with Source Isolated Connected with Load Isolated connected during the test.
Insulation Resistance Test

o Ground all conductors not under test for

Cable Temperature: C Temperature Correction Factor for 20oC:
each reading.

Test Insulation Resistance (MΩ)

Test Summary
Voltage
A-GND B-GND C-GND Test Passed
Test Inconclusive
Reading Further Investigation Required.
2500V Test Failed
Corrected to 20oC

Comments:

Form CBL-4160V Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-CBL-4160V.doc
 INSPECTION FORM Page 2 of 3
4160V POWER CABLE Cable ID:

Source:
Cable Dest. / Load:
Disconnected
Disconnected Note: Approval of City’s Representative is required, prior to
Test Preparation: Connected with
Connected with leaving cables connected during the test.
Source
Load Isolated
Isolated

Frequency: 0.1 Hz Waveform: sinusoidal Ground all conductors not under test for each reading.

Test Elapsed Peak Leakage Current (uA) Test Summary

Voltage Time
(RMS) (min) A-GND B-GND C-GND Test Passed
Test Inconclusive
7000V 0 Further Investigation Required.
Test Failed
7000V 1

7000V 2
Very Low Frequency (VLF) Test

7000V 3

7000V 4
High Potential

7000V 5

7000V 6

7000V 7

7000V 8

7000V 9

7000V 10

7000V 11

7000V 12

7000V 13

7000V 14

7000V 15

Comments:

Form CBL-4160V Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-CBL-4160V.doc
 INSPECTION FORM Page 3 of 3
4160V POWER CABLE Cable ID:

Frequency: 0.1 Hz Waveform: sinusoidal

Test Voltage A B C
(RMS)
Tan Capacitance Current Tan Capacitance Current Tan Capacitance Current
Delta (nF) (µA) Delta (nF) (µA) Delta (nF) (µA)
(Tangent Delta) Test
Dissipation Factor

2400V

4800V

Difference

Test Summary Comments:

Test Passed
Test Inconclusive
Further Investigation
Required.
Test Failed

Connection Resistance (µΩ) - As Left

Termination Torque Check
A B C
Connection
Resistance

Source OK

Dest. / Load OK

Comments:

Cable Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection

Yes No
Required:

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and that
the analysis results are correct.

Form CBL-4160V Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-CBL-4160V.doc
 INSPECTION FORM Page 1 of 1
POWER CABLE < 1000V Cable ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Source: Dest. / Load:

Manufacturer: Type: Conductor: Copper Aluminum

Cable Data

No. of AWG Measured Previous Data

Size: Length: m
Conductors: MCM Jacket Markings TDR
Operating
Rated Voltage: V V Date Installed:
Voltage:
Cable Tray EMT Alum. Conduit Direct Buried
Installation: Other:
Strapped Steel Conduit PVC Conduit Underground Duct

Physical Damage on Exposed Ends: Yes No Cable Identification Tag Installed: Yes No
Inspection
Visual

Visual Signs of Overheating: Yes No Cable Supported Appropriately: Yes No

Bend Radius Acceptable: Yes No Comments:

Source: Cable Dest. / Load: Note: Approval of City’s Representative

Test
Disconnected Disconnected is required, prior to leaving cables
Preparation:
Connected with Source Isolated Connected with Load Isolated connected during the test.
Insulation Resistance Test

Ground all conductors not under test for each

Cable Temperature: °C Temperature Correction Factor for 20°C:
reading.

Test Insulation Resistance (MΩ)

Test Summary
Voltage
A-GND B-GND C-GND N-GND Test Passed
Test Inconclusive
Reading Further Investigation Required.
V Test Failed
Corrected to 20oC

Utilize 1000VDC Test Voltage for 600V rated cables, 500VDC for cables rated <= 300V.

Comments:

Note: Torque check required for all cables. Connection Resistance Test required for cables 4/0 AWG or larger.
Connection Resistance

Connection Resistance (µΩ) - As Left

Termination Torque Check
A B C N

Source OK

Dest. / Load OK

Comments:

Cable Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection Required: Yes No

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Form CBL-LV Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-CBL-LV.doc
 Page 1 of 1
INSPECTION FORM
EMERGENCY LIGHTING ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Location: Fed From: Circuit #:

Battery Unit

Manufacturer: Model: Serial No:

Data

Input Voltage: V AC Input Current: A Output Voltage: V DC Wattage: W

Qty of Internal Lamps: Internal Lamp Wattage: W Type of Internal Lamps:

Quantity: Manufacturer: Model:

Fixtures
Remote

Input Voltage: V DC Input Current: A Qty of Lamps per Fixture:

Lamp Wattage: W Type of Lamps: Wire Size: AWG

Identification Tag Installed: Yes No Lamps Properly Aimed: Yes No

Inspection /
Cleaning

Visual signs of Moisture: Yes No Connections: Good Acceptable Poor

Visual

Cleanliness (As Found): Good Acceptable Poor Ground Connection: Good Acceptable Poor

Comments:

Equipment Temperature: °C Test Summary

Battery Testing

Test Results Test Passed

Test Inconclusive
Further Investigation Required.
Stated Design Time (From Drawings): Min Test Failed
Time Until Lamps Turn Off: Min

Comments:

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Inspection Required: Yes No

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and that
the analysis results are correct.

Form F-PNL-LV Rev 00, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Electrical\Forms\F-EMERG-LTG.doc
 INSPECTION FORM Page 1 of 1
GROUNDING/BONDING CONNECTION RESISTANCE Area:

Project Facility: Project Name:

Area : Bid Opportunity:

Resistance
Point A Point B Acceptable
(mΩ)

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive
Resistance Checks
(Ductor Test)

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Yes No Inconclusive

Comments:

Monitoring / Inspection Required: Yes No Comments:

Analysis
Final

Repair / Replacement Required: Yes No

Date
Company Name Signature
(yyyy/mm/dd)

Performed By

Checked By

Note: The person performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and that
the analysis results are correct.

Form F-GND-CONN_RES Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-GND_CONN_RES.doc
 INSPECTION FORM Page 1 of 3
GROUNDING SYSTEM ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Connection to Ground Electrode is

Yes No Facility Contains a Main Ground Bus: Yes No
Visible:
Visual Inspection

Connecting Conductor: Size: Qty: Torque Ground Connections: Yes No

Visual signs of Corrosion: Yes No

Soil Type: Soil Condition: Dry Damp Wet

Comments:

Date of Test: Time of Test:

Weather and Temperature: Terrain:

Grounding System UTM GPS

E N
Connection Point: Coordinate:
Current Probe UTM GPS
E N
Injection Point: Coordinate:

Test Conditions: Test Layout:

Voltage Probe Resistance @ Resistance @

Test Current Test Voltage
Distance UTM GPS Coordinate: Hz Hz
(mA) (mV)
(meters) (Ω) (Ω)
Fall Of Potential Test #1

E N

E N

E N

E N

E N

E N

E N

E N

E N

E N

E N

E N

Comments:

Form F-GROUNDING Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-GROUNDING.doc
 INSPECTION FORM Page 2 of 3
GROUNDING SYSTEM ID:

Date of Test: Time of Test:

Weather and Temperature: Terrain:

Grounding System UTM GPS

E N
Connection Point: Coordinate:
Current Probe UTM GPS
E N
Injection Point: Coordinate:

Test Conditions: Test Layout:

Voltage Probe Resistance @ Resistance @

Test Current Test Voltage
Distance UTM GPS Coordinate: Hz Hz
(mA) (mV)
(meters) (Ω) (Ω)
Fall Of Potential Test #2

E N

E N

E N

E N

E N

E N

E N

E N

E N

E N

E N

E N

Comments:

Form F-GROUNDING Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-GROUNDING.doc
 INSPECTION FORM Page 3 of 3
GROUNDING SYSTEM ID:

Resistance Test Summary

Point A Point B
(mΩ)
Test Passed
Test Inconclusive
Facility Ground Electrode Main Ground Bus Further Investigation Required.
Test Failed
Facility Ground Electrode 4160V Switchgear GND Bus

Facility Ground Electrode System Neutral

Facility Ground Electrode 600V Switchgear GND Bus

Resistance Checks
(Ductor Test)

Facility Ground Electrode MCC : GND Bus

Facility Ground Electrode MCC : GND Bus

Facility Ground Electrode Other :

Facility Ground Electrode Other :

Facility Ground Electrode Other :

Comments:

Monitoring / Inspection Required: Yes No Comments:

Analysis
Final

Repair / Replacement Required: Yes No

Date
Company Name Signature
(yyyy/mm/dd)

Performed By

Checked By

Note: The person performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and that
the analysis results are correct.

Form F-GROUNDING Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-GROUNDING.doc
 Page 1 of 6
INSPECTION FORM
MCC, 600V ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Location: # of Cells:
MCC Data

Manufacturer: Model: Serial #:

Rated Voltage: V Main Bus Rating: A Main Bus Neutral Rating: A

Bus Conductor: Copper Aluminum Current Withstand Rating: A

Identification Tag Installed: Yes No Visual Signs of Overheating: Yes No

Visual Signs of Moisture: Yes No Visual Signs of Corona: Yes No

Fuse/Breaker Sizes Match Drawings: Yes No PT and CT ratios match drawings: N/A Yes No

Elevation Drawings Correct: Yes No Cables Supported Appropriately: Yes No

Visual Inspection / Cleaning

Cleanliness (As Found): Good Acceptable Poor Insulators Condition: Good Acceptable Poor

Electro/Mechanical
Connections: Good Acceptable Poor Good Acceptable Poor
Interlock System:

Ground Connection: Good Acceptable Poor Vents/Filters: Good Acceptable Poor

Doors Mechanical: Good Acceptable Poor Exercise Active Components: Yes No

Cell Fit and Alignment: Good Acceptable Poor

Required Clearances are

Good Acceptable Poor
Met:

Indicating mechanisms: Good Acceptable Poor Unit Cleaned: Yes Photograph Taken: Yes

Comments:

Type: Inspection

Main Breaker Complete appropriate breaker inspection form.

Incoming Power

Disconnect Complete appropriate disconnect inspection form.

Visual Inspection: Good Acceptable Poor

Connections Torqued: Yes

Main Lugs
Connection A B C N
Resistance (μΩ)
As Left

Form F-MCC-600V Rev 01, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MCC-600V.doc
 Page 2 of 6
INSPECTION FORM
MCC, 600V ID:

Source:
Cable Dest. / Load: Note: Approval of City’s Representative is
Test Disconnected
Disconnected required, prior to leaving cables connected during
Preparation: Connected with Source
Connected with Load Isolated the test.
Isolated
Insulation Resistance Test

Temperature: °C

Test Insulation Resistance (MΩ)

Test Summary
Voltage Phase To Phase
(Buswork)

(dc) A-B B-C C-A Test Passed

Test Inconclusive
1000 V Further Investigation Required.
Test Failed
Insulation Resistance (MΩ)
Test Phase To GND
Voltage
A - GND B - GND C - GND

1000 V

Comments:

Test Summary
Resistance
Point A Point B
Checks (Ductor Test)

(μΩ)
Ground Resistance

Test Passed
Test Inconclusive
MCC GND Bus Facility Ground Electrode Further Investigation Required.
Test Failed
MCC GND Bus MCC Enclosure

MCC GND Bus System Neutral

Comments:

Visual Inspect Requirements: G=Good, A=Acceptable, P=Poor Comments are required for all items identified in Poor condition.

1. Confirm identification tag / lamacoid is installed.

2. Look for visual signs of overheating.

3. Inspect and torque connections.

4. Inspect and test any electro/mechanical interlocks.

Feeder Breakers

5. Confirm disconnect operation.

6. Check door mechanical condition.

7. Exercise circuit breaker.

8. Confirm cables are supported and routed appropriately.

9. Visually assess the general condition of the installation.

Note: Complete an appropriate Breaker Inspection Form for all breakers with separate adjustable Long and
Short trip settings, Ground trip settings, or > 250A frame size.
Continued on next page

Form F-MCC-600V Rev 01, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MCC-600V.doc
 Page 3 of 6
INSPECTION FORM
MCC, 600V ID:

Continued from previous page

Trip Rating

Inspection
Rating (A)

Cleaned
Frame

Visual
Loc./ Trip Unit

(A)
ID Manuf. Model Inst Setting Comments
Cell Type
Feeder Breakers

General
Comments:

Form F-MCC-600V Rev 01, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MCC-600V.doc
 Page 4 of 6
INSPECTION FORM
MCC, 600V ID:

Overcurrent Protection Type: B=Breaker (Thermal Magnetic), M=Motor Circuit Protector, F=Fuse

Overload Protection Type: T=Thermal, SS=Solid State, I=Intelligent

Visual Inspect Requirements: G=Good, A=Acceptable, P=Poor Comments are required for all items identified in Poor condition.

1. Confirm identification tag / lamacoid is installed.

Motor Starters / Contactors

2. Look for visual signs of overheating.

3. Inspect and torque connections.

4. Inspect and test any electro/mechanical interlocks.

5. Confirm disconnect operation.

6. Check door mechanical condition.

7. Exercise circuit breaker.

8. Confirm cables are supported and routed appropriately.

9. Visually assess the general condition of the installation.

Note: Complete a Motor Starter Inspection Form for all Motor Starters Size 4 or larger, with VFDs, or with Soft
Starters.

Overcurrent Protection Contactor Overload

Visual Insp.
Rating (A)

Loc./
ID Comments
Type

Type
Size /

Cleaned
Cell Manuf. Model Model
Rating
Motor Starters / Contactors

General
Comments:

Form F-MCC-600V Rev 01, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MCC-600V.doc
 Page 5 of 6
INSPECTION FORM
MCC, 600V ID:

Overcurrent Protection Contactor Overload

Visual Insp.
Rating (A)
Loc./
ID Comments

Type

Type
Size /

Cleaned
Cell Manuf. Model Model
Rating
Motor Starters

General
Comments:

Form F-MCC-600V Rev 01, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MCC-600V.doc
 Page 6 of 6
INSPECTION FORM
MCC, 600V ID:

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Inspection Required: Yes No

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person(s) performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and
that the analysis results are correct.

Form F-MCC-600V Rev 01, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MCC-600V.doc
 Page 1 of 2
INSPECTION FORM
MOTOR STARTER, FVNR, 600V ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Load: Starter Location: Cell #:

Manufacturer: Type: Serial #:

Size: Rated Voltage: V Current Rating: A Control Voltage: V

Fuse Mfg.
Fused Disc. Rating: A Fuse Size: A
Circuit Model:
Starter Data

Protection: Manufacturer:
Breaker Inst.
Rating: A A
MCP Setting: Model:

10 Manufacturer:
Thermal
Overload 20 Setting /
Electronic Class: A
Protection: 30 Rating:
Intelligent Model:
Unknown

Control Power
Size: VA Sec. Voltage: V Primary Fuse: A Secondary Fuse: A
Transformer:
A
Current Ground Present
Phases: B None Ratio: Ratio:
Transformers: Fault CT: Not Present
C

ID: Size: kW / HP Voltage: V

Motor
Data

Full Load Amps: A Service Factor: Other:

Starter Identification Tag Installed: Yes No Visual Signs of Overheating: Yes No

Cleanliness (As Found): Good Acceptable Poor Support Insulators: Good Acceptable Poor
Visual Inspection / Cleaning

Electro/Mechanical
Connections Good Acceptable Poor N/A Good Acceptable Poor
Interlock:

Ground Connection: Good Acceptable Poor Contactor Condition: Good Acceptable Poor

Door Mechanical Good Acceptable Poor Contact Alignment: Good Acceptable Poor

Verify O/L element is correctly sized for

Yes No Exercise Circuit Breaker/MCP/Disconnect Yes
the load:

Cables Supported Appropriately: Yes No Unit Cleaned: Yes Photograph Taken: Yes

Comments:

Test A B C Test Summary

Measurements
Contact/Pole

Contact Resistance (µΩ) Test Passed

Test Inconclusive
Disconnect / Breaker / MCP Further Investigation Required.
Resistance (µΩ) Test Failed

Fuse Resistance (µΩ)

Comments:

Form MS-FVNR-600V Rev 02, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MS-FVNR-600V.doc
 Page 2 of 2
INSPECTION FORM
MOTOR STARTER, FVNR, 600V ID:

Cable Dest. / Load:

Source: Isolated Note: Approval of City’s Representative is required,
Test Preparation: Disconnected
Contactor: Open prior to leaving cables connected during the test.
Connected with Load Isolated
Insulation Resistance Test

Insulation Resistance (MΩ)

Ground all phases not
Test Voltage
under test!
A B C

Contactor Line To GND 1000 VDC Test Summary

Test Passed
Contactor Load To GND 1000 VDC Test Inconclusive
Further Investigation
Required.
Contactor Line to Load 1000 VDC Test Failed

Comments:

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection

Yes No
Required:

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and that
the analysis results are correct.

Form MS-FVNR-600V Rev 02, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Forms\Electrical\F-MS-FVNR-600V.doc
 INSPECTION FORM Page: 1 of 2
AC MOTOR, LOW VOLTAGE ID:
Project
Facility: Project Name:

Area : Bid Opportunity:

Size: kW / HP Voltage: V R.P.M:

Motor Data

Manufacturer: Model: Serial Number:

Service
Frame Type: Other:
Factor:
Air Winding
Cooling: # Cooling Fans:
Fan Material:

Motor Identification Tag Installed: Yes No Visual Signs of Overheating: Yes No

Visual Inspection / Cleaning

Connections: Good Acceptable Poor Air Baffles: Good Acceptable Poor

Paint: Good Acceptable Poor Filter Media: N/A Good Acceptable Poor

Cooling Fans: N/A Good Acceptable Poor Fan Controls: N/A Good Acceptable Poor

Anchorage/Alignment: Good Acceptable Poor

Ground Connection: Good Acceptable Poor

Mechanical/Electrical Noise During

Yes No Lubrication Required: Yes No
Operation:

Cleanliness (As Found): Good Acceptable Poor Unit Cleaned: Yes Photograph Taken: Yes

Test Winding Resistance (MΩ) Dielectric Polarization

Stator Winding Voltage Absorption
Temperature (°C) 30 Sec 1 min. 10 min. (a) Index (a)
(Vdc) Ratio
Winding Insulation Resistance

- -
500
40

- -
500
40

- -
500
40

Notes:
(a) Testing to 10 minutes and calculation of Polarization Index is only required for motors > 150 kW (200 HP)
Test Summary Test Passed Test Inconclusive. Further Investigation Required. Test Failed

Resistance (µΩ) Test Summary

Resistance

A-B B–C A-C Test Passed

Winding

Test Inconclusive
Further Investigation Required.
Test Failed

Comments:

Form F-MTR-LV Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-MTR-LV.doc
 INSPECTION FORM Page: 2 of 2
AC MOTOR, LOW VOLTAGE ID:

Not Applicable
Bearing Insulation

Test Voltage Bearing Resistance (MΩ)

Bearing
Resistance

(Vdc) Temperature (°C) 1 min. Corrected to 40°C

500

500

Test Summary Test Passed Test Inconclusive. Further Investigation Required. Test Failed

Not Applicable
Actual Winding Temperature: °C Actual Bearing Temperature °C
Calculated Calculated
Resistance Resistance
RTD Temperature RTD Temperature
(Ω) (Ω)
(°C) (°C)
RTD Resistance

Test Summary Test Passed Test Inconclusive. Further Investigation Required. Test Failed

Note: Test connection resistance of bolted connections. Report on cable inspection sheet.

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection

Yes No
Required:

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By
Note: The person(s) performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and
that the analysis results are correct.

Form F-MTR-LV Rev 00, Created by SNC-Lavalin Inc.

M:\113099\4ENG\47ELE\RA - Misc Reports & Forms\Forms\F-MTR-LV.doc
 Page 1 of 2
INSPECTION FORM
VOLTAGE MONITOR, SSAC-WVM ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Location: Cell #:
Relay Data

Manufacturer: Model:

Type: Serial No.:

Comments:

A B C A B C
Visual Inspection

Moisture/Rust: Relay Cleaned:

Over-heating: Screws Tightened:

Cover/Case:

Legend: A-Acceptable C-Corrected N-Needs Repair NA-Not Applicable

Comments:

Setting Setting
Parameter
(As Found) (As Left)

Line Voltage
Relay Settings

Unbalance

Trip Delay

Restart Delay

Mode Switch

Desired Phase Voltage Actual Voltage

Relay State Time to Change OK
A B C A B C

600 600 600

Basic Voltage Tests

0 600 600

600 600 600

600 0 600

600 600 600

600 600 0

600 600 600

Comments:

Form F-RELAY-VM-SSAC-WVM Rev 00, Created by SNC-Lavalin Inc.

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 Page 2 of 2
INSPECTION FORM
VOLTAGE MONITOR, SSAC-WVM ID:

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection

Yes No
Required:

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person(s) performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and
that the analysis results are correct.

Form F-RELAY-VM-SSAC-WVM Rev 00, Created by SNC-Lavalin Inc.

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 INSPECTION FORM Page 1 of 2
TRANSFORMER, DRY TYPE, LOW VOLTAGE ID:

Project Facility: Project Name:

Area : Bid Opportunity:

Secondary
KVA: Phase: Primary Voltage: V V
Voltage:
Transformer Data

Manufacturer: Type: Serial Number:

Primary ∆ Secondary ∆
Impedance: %Z Temp Rise: °C K Factor:
Winding: Υ Winding: Υ

Winding Material: Copper Aluminum

No Load Tap Tap 1 2 3 4 5 Tap Setting

Changer (As Found):
Voltage

Transformer Identification Tag Installed: Yes No Visual Signs of Overheating: Yes No

Visual Inspection / Cleaning

Bushings: Good Acceptable Poor Support Insulators: Good Acceptable Poor

No Load Tap
Paint: Good Acceptable Poor N/A Good Acceptable Poor
Changer:

Fans: N/A Good Acceptable Poor Fan Controls: N/A Good Acceptable Poor

Temp. Gauge: N/A Good Acceptable Poor Connections: Good Acceptable Poor

Ground
Good Acceptable Poor Neutral Bonded to Ground: N/A Yes No
Connection:

Cleanliness (As Found): Good Acceptable Poor Unit Cleaned: Yes Photograph Taken: Yes

Operational Conditions / Notes:

Operational Inspection

Primary Voltage: H1:H2: V H2:H3: V H3:H1: V Measured at:

Secondary Voltage: X1:__: V X2:__: V X3:__: V Measured at:

Current: Ph A: A Ph B: A Ph C: A Measured at:

Appears Satisfactory
Tap Setting: Further Monitoring Recommended. Tap Setting (As Left):
Recommend Changing Tap.
Thermographic Inspection Attach report No Issues Found
Yes Results:
Performed: separately Potential Issue Identified.

Resistance (MΩ) Dielectric

Insulation Resistance

Test Voltage Absorption Ratio

Winding
(Vdc) 60s/30s
30 sec 60 sec.

Primary to Ground, Secondary Guarded

Secondary to Ground, Primary Guarded

Primary to Secondary, Ground Guarded

Form F-XFMR-DRY-LV Rev 02, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Electrical\Forms\F-XFMR-DRY-LV.doc
 INSPECTION FORM Page 2 of 2
TRANSFORMER, DRY TYPE, LOW VOLTAGE ID:

Analysis
Returned to Service: Yes No Comments:
Final

Monitoring / Further Inspection

Yes No
Required:

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person(s) performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and
that the analysis results are correct.

Form F-XFMR-DRY-LV Rev 02, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Electrical\Forms\F-XFMR-DRY-LV.doc
 INSPECTION FORM Page: 1 of 3
TRANSFORMER, LIQUID-FILLED, MEDIUM VOLTAGE ID:

Project Facility: Project Name:

Area : Bid Opportunity:

KVA: / / Phase: Primary Voltage: V Secondary Voltage: V

Manufacturer: Model: Serial Number:

Transformer Data

Primary ∆ Secondary ∆
Impedance: %Z Temp Rise: °C K Factor:
Winding: Υ Winding: Υ
ONAN Winding
Cooling: # Cooling Fans: Oil Type:
ONAF Material:

BIL Rating Primary: BIL Rating Secondary: Oil Capacity:

No Load Tap Tap 1 2 3 4 5 Tap Setting

Changer (As Found):
Voltage

Transformer Identification Tag Installed: Yes No Visual Signs of Overheating: Yes No

Bushings: Good Acceptable Poor Support Insulators: Good Acceptable Poor

Visual Inspection / Cleaning

No Load Tap
Paint: Good Acceptable Poor N/A Good Acceptable Poor
Changer:

Fans: N/A Good Acceptable Poor Fan Controls: N/A Good Acceptable Poor

Temp. Gauge: N/A Good Acceptable Poor Connections: Good Acceptable Poor

Ground
Good Acceptable Poor Liquid Level Correct: Yes No
Connection:

Ground Conductor Size: Radiators: Good Acceptable Poor

Cleanliness (As Found): Good Acceptable Poor Unit Cleaned: Yes Photograph Taken: Yes

Operational Conditions / Notes:

Primary Voltage: H1:H2: V H2:H3: V H3:H1: V Measured at:

Secondary Voltage: X1:__: V X2:__: V X3:__: V Measured at:

Operational Inspection

Current: Ph A: A Ph B: A Ph C: A Measured at:

Appears Satisfactory
Tap Setting: Further Monitoring Recommended. Tap Setting (As Left):
Recommend Changing Tap.
Cooling Temperature:
Coolant Level:
o o
Gauges: Current C Maximum: C

Pressure/Vacuum: Other:

Thermographic Inspection Attach report No Issues Found

Yes Results:
Performed: separately Potential Issue Identified.

Form F-XFMR-LIQ-MV Rev 01, Created by SNC-Lavalin Inc.

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 TRANSFORMER INSPECTION FORM Page: 2 of 3
TRANSFORMER, LIQUID-FILLED, MEDIUM VOLTAGE ID:

o o
Winding Temperature: C Temperature Correction Factor (20 C):

Resistance (MΩ)

PRI-GND SEC-GND PRI-SEC

Time Test Voltage: Test Voltage: Test Voltage:

Corrected to Corrected to Corrected to

Reading o Reading o Reading o
20 C 20 C 20 C

1 min.
Insulation Resistance

2 min.

3 min.

4 min.

5 min.

6 min.

7 min.

8 min.

9 min.

10 min.

Polarization
Index

o
Winding Temperature: C
Winding Resistance

Winding Winding Resistance (mΩ) Winding Winding Resistance (mΩ)

H2 – H1 X0 – X1

H3 – H2 X0 – X2

H3 – H1 X0 – X3

Measured Ratios
Ratio Test

Tap Primary Secondary Calculated

Turns

(Designated) Voltage (V) Voltage (V) Ratio

H3 H1 / X0 X1 H1 H2 / X0 X2 H2 H3 / X0 X3

Note: Torque check required for all cables. Connection Resistance Test required for cables 250MCM or larger.

Connection Resistance (µΩ) - As Left

Connection
Resistance

Termination Torque Check

A B C N

Source OK

Dest. / Load OK

Form F-XFMR-LIQ-MV Rev 00, Created by SNC-Lavalin Inc.

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 TRANSFORMER INSPECTION FORM Page: 3 of 3
TRANSFORMER, LIQUID-FILLED, MEDIUM VOLTAGE ID:

Dielectric Breakdown
Colour:
Voltage:
Insulating Liquid

Acid Neutralization
Visual Condition:
Tests

Number:
Power Factor or
Specific Gravity:
Dissipation Factor:
Dissolved Gas
Other:
Analysis:

Returned to Service: Yes No Comments:

Analysis
Final

Monitoring / Further Inspection

Yes No
Required:

Repair / Replacement Required: Yes No

Company Name Signature Date (yyyy/mm/dd)

Performed By

Checked By

Note: The person performing the check is responsible for ensuring that the data is transcribed from the handwritten form correctly, and that
the analysis results are correct.

Form F-XFMR-LIQ-MV Rev 00, Created by SNC-Lavalin Inc.

L:\40ENG\Clients\City of Winnipeg\Electrical\Forms\F-XFMR-LIQ-MV.doc