+-----------------------------+----------------+----------------------+
| Candidate Name:             | Life/Gu        | Department/Division: |
|                             | est/Contractor |                      |
|                             | Number:        |                      |
+-----------------------------+----------------+----------------------+
| Evaluator Name              | Date JPM       | Bldg. No. where JPM  |
|                             | Completed:     | Performed:           |
+-----------------------------+----------------+----------------------+
| Evaluator Name              | Date JPM       | Bldg. No. where JPM  |
|                             | Completed:     | Performed:           |
+-----------------------------+----------------+----------------------+
| Evaluator Name              | Date JPM       | Bldg. No. where JPM  |
|                             | Completed:     | Performed:           |
+-----------------------------+----------------+----------------------+
| LESC Approval               |  Approved     | Date:                |
|                             |                |                      |
|                             |  Disapproved  |                      |
+-----------------------------+----------------+----------------------+

+---+-----------------------+------------------------------+---+---+---+
|   | **Steps**             | **Standard**                 | * | * | * |
|   |                       |                              | * | * | * |
|   |                       |                              | P | F | H |
|   |                       |                              | a | a | o |
|   |                       |                              | s | i | l |
|   |                       |                              | s | l | d |
|   |                       |                              | * | * | * |
|   |                       |                              | * | * | * |
+===+=======================+==============================+===+===+===+
| 0 | Categorize Equipment  | -   BNL Built                |   |   |   |
| 1 |                       |                              |   |   |   |
|   |                       | -   Commercial Equipment     |   |   |   |
|   |                       |     Modified By BNL          |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Custom Built to BNL      |   |   |   |
|   |                       |     Specs                    |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Commercial Off-the-Shelf |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   NRTL                     |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify Proper         | -   No openings in           |   |   |   |
| 2 | Enclosure             |     enclosure; or            |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   No exposure to hazardous |   |   |   |
|   |                       |     voltages                 |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify grounding and  | -   All exposed metal        |   |   |   |
| 3 | bonding               |     surfaces are grounded    |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Equipment is properly    |   |   |   |
|   |                       |     grounded/bonded          |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify adequate       | -   Input conductors are     |   |   |   |
| 4 | overcurrent           |     rated for worst-case     |   |   |   |
|   | protection            |     current                  |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Complete              | -   Complete inspection form |   |   |   |
| 5 | administrative        |                              |   |   |   |
|   | process               | -   Apply barcode and labels |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Submit or enter data     |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Other                 |                              |   |   |   |
| 6 |                       |                              |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
|   | Evaluator Signature:  |                              |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Categorize Equipment  | -   BNL Built                |   |   |   |
| 1 |                       |                              |   |   |   |
|   |                       | -   Commercial Equipment     |   |   |   |
|   |                       |     Modified By BNL          |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Custom Built to BNL      |   |   |   |
|   |                       |     Specs                    |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Commercial Off-the-Shelf |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   NRTL                     |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify Proper         | -   No openings in           |   |   |   |
| 2 | Enclosure             |     enclosure; or            |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   No exposure to hazardous |   |   |   |
|   |                       |     voltages                 |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify grounding and  | -   All exposed metal        |   |   |   |
| 3 | bonding               |     surfaces are grounded    |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Equipment is properly    |   |   |   |
|   |                       |     grounded                 |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify adequate       | -   Input conductors are     |   |   |   |
| 4 | overcurrent           |     rated for worst-case     |   |   |   |
|   | protection            |     current                  |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Complete              | -   Complete inspection form |   |   |   |
| 5 | administrative        |                              |   |   |   |
|   | process               | -   Apply barcode and labels |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Submit or enter data     |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Other                 |                              |   |   |   |
| 6 |                       |                              |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
|   | Evaluator Signature:  |                              |   |   |   |
+---+-----------------------+------------------------------+---+---+---+

+---+-----------------------+------------------------------+---+---+---+
|   | **Steps**             | **Standard**                 | * | * | * |
|   |                       |                              | * | * | * |
|   |                       |                              | P | F | H |
|   |                       |                              | a | a | o |
|   |                       |                              | s | i | l |
|   |                       |                              | s | l | d |
|   |                       |                              | * | * | * |
|   |                       |                              | * | * | * |
+===+=======================+==============================+===+===+===+
| 0 | Categorize Equipment  | -   BNL Built                |   |   |   |
| 1 |                       |                              |   |   |   |
|   |                       | -   Commercial Equipment     |   |   |   |
|   |                       |     Modified By BNL          |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Custom Built to BNL      |   |   |   |
|   |                       |     Specs                    |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Commercial Off-the-Shelf |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   NRTL                     |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify Proper         | -   No openings in           |   |   |   |
| 2 | Enclosure             |     enclosure; or            |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   No exposure to hazardous |   |   |   |
|   |                       |     voltages                 |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify grounding and  | -   All exposed metal        |   |   |   |
| 3 | bonding               |     surfaces are grounded    |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Equipment is properly    |   |   |   |
|   |                       |     grounded                 |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Verify adequate       | -   Input conductors are     |   |   |   |
| 4 | overcurrent           |     rated for worst-case     |   |   |   |
|   | protection            |     current                  |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Complete              | -   Complete inspection form |   |   |   |
| 5 | administrative        |                              |   |   |   |
|   | process               | -   Apply barcode and labels |   |   |   |
|   |                       |                              |   |   |   |
|   |                       | -   Submit or enter data     |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
| 0 | Other                 |                              |   |   |   |
| 6 |                       |                              |   |   |   |
+---+-----------------------+------------------------------+---+---+---+
|   | Evaluator Signature:  |                              |   |   |   |
+---+-----------------------+------------------------------+---+---+---+