# UNDER WRITERS LABORATORIES INC. _NORTIIBROOK, IL U.S.A. CONFORMITY ASSESSMENT SER VICES

SECTION 3 d 15DNBK Date: February 7, 2002 Name: Jim Raba Organization : U.S. Department of Energy Fax Number: (202) 586-4617 FROM: Lenore J. Berman Transmission consists of cover sheet, plus 7 pages. Subject: Client Facility Assessment Form Message: In response to your February - 6, 2002 e-mail, attached is a copy of the Client Facility Assessment Form that is contained in Appendix C of the Motor Efficiency Guide and the page titled Assessment of Client Facility. Regards; 

## 17 Lenore J. Berman Associate Manager Office Phone No. (847) 272- 8800 , Ext. (42848) Section Fax No. (847) 509-6226 Lenore.J.nerman@us.ul.com

THIS MESSAGE IS IN'I'FNDED ONLY POR THEE I AE OE'I'HE INDIVIDIJAI.OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL, AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. If the reader of this rnessune is not the intended rccipicnL or the employee or agent responsible for delivering the messuge to the intended recipient, you are hereby notified that any dissemination , distribution, or copying of this communication is strictly prohibited. If you have received the communication in error, please notify us immediately by telephone ( collect) and return the original message to us at the above address via the U.S. Postal Services,Motor Efficiency Guide Issued : May 14, 2001 Revised: October 22, 2001 ASSESSAMNT OF CLIENT FACILITY 

### During the investigation of a client facility the following aspects of the manufacturer's testing outfit will be reviewed: 1. Quality System - (ISO 9001 or 9002 registered or similar quality assurance program in place) 2. Qualified Personnel - (Witness proficiency of each lab techniciao/technical reviewer) 

### 3. Lab Environment - (Stable, draft free environment at 10-40°C) 4. Measurement/Instnunentation Accuracy: 

### General - Indicating instrumentation shall be calibrated to limit errors to no greater than the specified value. a. Voltage, Current, and Power: +/- 0.29/o of full scale h. Instrumentation Transformers: <= 0.3% c. Speed: +/- 1 RPM of the measured value d. Torque: +/- 0.2% of full scale NOTE: If the measurement instruments and instrumentation transformers in Items a and b are calibrated as a system, the accuracy shall be +/- 0,2% of full scale. 5. Power Supply: 

### a. Phase Voltage Balance: 0.5 % of specified value b. Average Frequency : +/- 10% of specified value c. Average Frequency Stability : <= 0.33% d. Waveform Deviation Factor: <^= 10% 6. Calibration - (All equipment used must be annually calibrated by a body that can provide traceability to national standard of measurement) 

### 7. Standards - Per DOE test procedure 10 CFR Part 431.23 dated October 5, 1999 or CSA C390-93, Energy Efficiency Test Methods for Three-Phase Induction Motors, 8. Client Facility Assessment Form - See Appendix C for example.

14Motor Efficiency Guide

Appendix C Issued : May I4, 2001



## ASSESSMENT OF CLIENT TEST

TEST FACILITY IDENTIFICATION SHEET Name : Address: Tel: FAX: Telex: Contact Person: UL Personnel Technical Auditor Reviewer Name: Title: Dept: 3018X Office: Northbrook Signature: 

### Scope of Assessment Product Category(i es):(List caregaries client is caveredfor)

Standard(s):(List Standards client uses in lab)Motor Efficiency Guide Issued: May 14, 2001

Appendix C

Tests: (Llst rests client is covered for 0 

### 11

• 0 $

0 O 0

• a 11
• 

### Test Standards Y N CTDP Requirement

Has standards for testing to be performed: Std - 

### Std - Std - Std - Standards are accessible to personnel involved with testing. Procedures in place to keep standards current (e.g., UL subscription service in conjunction with internal distribution system)- Test Facilities 

### List of test facilities needed to perform tests. Facilities Needed Available (Y/N)Motor Efficiency Guide

Appendix C 

### Measurement & Test Equipment (M&TE) Equipment Equipment Name Specifications 

### Available (Y/N)

I Calibrated

(YTi) Issued : May 14, 2001



### Equipment Reviewed Details



### Measurement & Test Equipment (M&TE) Calibration and Maintenance
Y N CTDP Requirement

Has inventory list (e
. g., tabulation
. index cards, computer database) of measurement and test equipment (M&TE.)? System in place to schedule calibration of M&TE_ 

### Equipment calibrated periodically. Calibration must be at least annually unless: 1, i'vt&TE manufacturer recommends a different interval,

2, Statistical calibration history study justifies a different interval, 3. Calibrated bgfare each use. Calibrations traceable to nationally or internationally recognized standard of measurement (e.g., NIST). Maintains the following M&TE records: 

### 1. Instruction and maintenance manuals (unless the M&TE is simple and straight forward to use and maintain). 2. Full identification of the M&TE and records of its acquisition. a. History of damage, malfunction. maintenance and repair. 

### 4. Calibration certificates.Motor Efficiency Guide Issued : May 14, 2001

Appendix C 

### Out-of-tolerance trace back system - Procedures shall be in place to

determine what test data has been acquired by a defective instrument and UL notification. Test Performance List 

### List of Tests Observed During Assessment Standard Test Observed Performed No. Name OK(Y,N)

Test Qualification List (TQL) 

### Standard Nu -fiber Standard Title Test Name



### Laboratory Personnel Qualification Log (LPQL) Comments

Personnel are sufficiently independent and free from financial or other pressure which may affect the conduct of tests and reporting of results. Personnel considered to have the necessary education, training, technical knowledge and experience to perform the testing noted, 

### Standard Test Name ^ Name of Person(s) ( Qualified Reviewer

LMotor Efficiency Guide

Appendix C Issued : May 14, 2001 

### 1

Data Recording Procedures Checklist General 

### Sample Identification: ( ) -'Manufacturer ( ) - Model number, type number, serial number ( ) Ratings ( ) - Date received ( ) - Sample number ( ) - Multiple sample identification and correlation to tests performed () Other description as needed to define sample tested 

### ( ) - Log of changes made to samples during test program Test Method Description: { ) - Complete description of test method used or reference to standard ( organization, number, edition, date) and test (name, section in standard). 

### { ) - Description of deviations from method in standard. Record of Results: ( ) - All data required by Standard. 

### ( ) - Test parameters (e-g., ambient temperature, humidity, air velocity) defining test conditions. - Other observations which may bear on understanding and interpretation- of test conditions or data obtained. Test Equipment: Identify all measurement and test equipment used and correlate to test performed and data obtained. { ) - Instrument type (e.g_, voltmeter, shunt, barometer) 

### O Identification (manufacturer, model number, serial number, meter number). () Range used. ( } - Last calibration date. ( ) - Calibration due date. Data Sheets: ( ) - Location where test performed (company name and address) () UL file number ( ) - UL project number ( ) - Test date 

### ( ) - Test title O Technician name and signature (each page) ( ) - Client uses signature on file and keeps a log of signatures. ( ) - Responsible engineer name and signature (on data package) ( ) - Use UL form data sheets where availableMotor Efficiency Guide Issued: May I4, 2001

Appendix C 

### ( -Use ink ( ) - No erasures ( ) - Error correction by lining out erroneous data, and noting change. reason for change and person making change. ( ) - Chart paper, computer paper, printouts, and the like; follow rules for data sheets and include parameters such as chart speed, sealing factors, etc.


### Data Recording Procedures Checklist List all data recording procedures specific to standards or categories being covered.



### Closing Session Record of Attendance

Name 

### I Title Department/Company I

1

SUMMARY OF NON-CONFORMANCES 

### Discussed During Closing Session