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Data:
FISA DE REVIZIE POMPE
Beneficiar, adresa
: __________________________________________________________________
Echipament / model
: ______________________________/____________________________________
Persoana de contact
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Cod
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Data
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MODEL ECHIPAMENT
OPERATIE EFECTUATA SI
MARIMI MASURATE
DA
NU
VAL.
Comenta
MAS
rii/ stare
(daca e
cazul)
1
2
1
2
3
1
2
4
1
Pompa de drenaj
(TM; TMW)
4
ECHIPAMENT IN FUNCTIUNE
NU
BAZA
PRECIZARI____________________________________________________________________________________
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EXECUTANT,
___________________
(nume, prenume, semnatura si stampila)
BENEFICIAR,
________________________________________
(nume, prenume, semnatura si stampila)