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Rapporto di ispezione per impianti termici a combustione VERIFICA DELLO STATO DI MANUTENZIONE ED ESERCIZIO DEGLI IMPIANTI TERMICI - GRUPPI TERMICI - STAGIONE 2___ - 2___ (ai sensi del DPR 74/2013 e DGR 3965/2015 e loro successive modifiche ed integrazioni) Foglio n° 1 di ……….. 1. DATI GENERALI a) Catasto impianti/codice ……..……...…. d) Dichiarato Si F1RF b) Data ispezione …………….…..…. N° ..…..… c) Ispettore/estremi qualifica ……………………...…… e) N° dichiarazione ………………...…… Comune g) UBICAZIONE: Indirizzo f) Data dichiarazione ……………….…….....………… Località Scala Piano Dati catastali: Sezione ……………; Foglio………………….; Particella……………………………; Subalterno ……………………………………… h) Delegato : Cognome e nome Indirizzo Occupante F Terzo responsabile (manutentore) F Proprietario/i FAmministratoreF k) Proprietario Ragione sociale Cognome e nome Indirizzo Comune Telefono Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax Fax Ragione sociale Ragione sociale m) Amministratore l) T.R. / Manutentore j) Occupante i) Responsab ile impianto: Cognome e nome Indirizzo Comune Telefono Fax Cognome e nome Indirizzo Comune Telefono Fax 2. DESTINAZIONE a) Destinazione prevalente dell'immob ile b) Centrale a servizio di: c) Destinazione d'uso dell'impianto FTerziario/Artigianale/Industriale F Più unità immobiliari F Produzione di acqua calda sanitaria FResidenziale FEdificio pubblico od a uso pubblico F Altro …………..……...………….… FSingola unità immobiliare FRiscaldamento ambienti e) Superficie riscaldata …………………….. f) Consumi ……… (m 3/anno) ………. (kg/anno) ……… (l/anno) F Si F No F NC a) Installazione interna: locale idoneo F Si F No F NA c) Sistema di ventilazione sufficiente F Si F No F NA i) Assenza perdite combustibile (esame visivo) k) Trattamento dell'acqua riscaldamento produzione ACS F Si F No F NC FNon Richiesto FNon Richiesto FGas naturale FGPL FGasolio FAltro ……..…….……… 3. VERIFICA LOCALE F Si F No F NA e) Cartellonistica prevista presente g) Interruttore generale presente d) Comb ustib ile F Si F No F NC b) installazione esterna: generatori idonei F Si F No F NC d) Sistema evacuazione fumi idonea (esame visivo) F Si F No F NA f) mezzi estinzione incendi presenti e revisionati F Si F No F NA h) Rubinetto intercettazione esterno presente j) Sistema regolazione temp. ambiente funzionante FAssente FAssente F Filtrazione F Filtrazione F Addolcimento F Addolcimento F Si F No F NC FCond. chimico FCond. chimico 4. STATO DELLA DOCUMENTAZIONE F Si F No a) Libretto impianto presente F Si F No c) Dich. di conformità/rispondenza presente F Si F No F NA e) C.P.I. presente ove richiesto a) Check-list F Si F No b) Libretto di impianto compilato in tutte le parti d) Libretti uso e manutenzione generatori/impianto presenti f) Pratica INAIL (ISPESL) presente ove richiesta F Si F No F Si F No F NA 5. INTERVENTI DI MIGLIORAMENTO ENERGETICO FAdozione valvole termostatiche su corpi scaldanti FIsolamento della rete di distribuzione nei locali non riscaldati FIntroduzione di un sistema di trattamento acqua FSostituzione sistema regolazione on/off con uno programmabile FNon sono stati individuati interventi economicamente convenienti b) Interventi atti a migliorare il rendimento energetico c) Stima del dimensionamento del/i generatori FSi allega relazione di dettaglio FSi rimanda a relazione di dettaglio successiva FValutazione non eseguita, motivo: …………………………………………………………………. FDimensionamento corretto FNon controllabile FDimensionamento non corretto FSi rimanda a relazione di dettaglio successiva – 78 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Foglio n° ….…. di .……. Catasto impianti/codice …….………...… a) Data realizzazione impianto c) Data installazione gen. e) Tipologia gruppo termico f) Classificazione Data della verifica …...…....……… N° ……… 6. GENERATORE b) Generatore FSingolo FStandard N…………. di ………. d) Fluido termovettore FModulare FTubo o nastro radiante F a bassa temperatura j) Costruttore bruciatore h) Modello caldaia k) Modello bruciatore m) Dati nominali FGeneratore ad aria calda Fa gas a condensazione g) Costruttore caldaia i) Matricola caldaia F Acqua F Aria F Altro……… l) Matricola bruciatore Pot. termica al focolare …….(kW) ; Pot. termica utile …… (kW) ; Campo di lavoro bruciatore da ……. a …… (kW) n) Dati misurati Portata di combustibile ……. (m3/h o kg/h) ; Pot. termica al focolare …… (kW) 7. MANUTENZIONI a) Operazioni di controllo e manutenzione: Frequenza …………… Ultima manutenzione prevista effettuata b) Rapporto di controllo tecnico Presente F Si F No F Sì F No Data:…………… Con: FOsservazioni FRaccomandazioni FPrescrizioni 8. MISURA DEL RENDIMENTO DI COMBUSTIONE (UNI 10389-1) Strumento: Marca …….……… Modello……….…. Matricola …….….. b) Bacharach (per comb ustib ili liquidi) 1° misura ……..; 2° misura ………; 3° misura…….. a) Modulo tetmico N. …… di ……. c) Valori misurati (media delle tre misure) d) Valori calcolati Temperatura fluido di mandata (°C) Temperatura aria comburente (°C) Temperatura fumi (°C) F CO2 oppureF O2 (%) Indice d'aria (n) CO nei fumi secchi e senz'aria (ppm) Potenza termica persa al camino Qs (%) Recupero calore di condensazione ET (%) CO nei fumi secchi (ppm) Rendimento di combustione ? comb (%) e) MISURA DEL TIRAGGIO (UNI 10845) Strumento: Marca…....…..…… Modello……..……... Matricola……..……….... 9. RISULTATI DELL'ISPEZIONE F Regolare a) Monossido di carbonio nei fumi secchi e senz'aria: (deve essere inferiore o uguale a 1000 ppm = 0,1%) (Pa) F Irregolare F Regolare F Irregolare b) Indice di fumosità - N° di Bacharach: (deve essere: per l'olio combustibile inferiore o uguale a 6 per il gasolio inferiore o uguale a 2) F Sufficiente F Insufficiente c) Rendimento di combustione: (il valore deve essere superiore o uguale a ………. %) F Sì F No d) L'impianto rispetta la normativa? (relativamente al DPR 74/2013 e DGR 3965/2015 e ss.mm.ii.) Valore rilevato ………..… % Valore rilevato + 2 …………… % e) L'impianto rispetta quanto previsto ai punti del presente rapporto: F 7.a F 9.a F 9.b F 9.c 10. OSSERVAZIONI DELL'ISPETTORE 11. PRESCRIZIONI DELL'ISPETTORE b) Codici elenco non conform …… ….; ………..; ………..; ………..; ………..; ………..; ………..; ………..; 12. DICHIARAZIONI DEL RESPONSABILE IMPIANTO RESPONSABILE IM PIANTO O SUO DELEGATO PER RICEVUTA …………………………………………………………. L'ISPETTORE ………………………………………… Bollettino Ufficiale – 79 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 1B - Rapporto di ispezione per macchine frigorifere / pompe di calore VERIFICA DELLO STATO DI MANUTENZIONE ED ESERCIZIO DEGLI IMPIANTI TERMICI - GRUPPI FRIGO - STAGIONE 2___ - 2___ (ai sensi del DPR 74/2013 e DGR 3965/2015 e loro successive modifiche ed integrazioni) Foglio n° 1 di ……….. 1. DATI GENERALI a) Catasto impianti/codice ……..……...…. d) Dichiarato Si F1RF b) Data ispezione …………….…..…. N° ..…..…c) Ispettore/estremi qualifica ……………………...…… e) N° dichiarazione ………………...…… Comune f) Data dichiarazione ……………….…….....………… Località g) UBICAZIONE: Indirizzo Scala Piano Dati catastali: Sezione ……………; Foglio………………….; Particella……………………………; Subalterno ……………………………………… k) Proprietario Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax Ragione sociale m) Amministratore l) T.R. / Manutentore j) Occupante h) Delegato : Cognome e nome Indirizzo i) Responsabile impianto: Occupante F Terzo responsabile (manutentore) F Cognome e nome Indirizzo Comune Telefono Fax Proprietario/i FAmministratoreF Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax 2. DESTINAZIONE a) Destinazione prevalente dell'immobile FResidenziale FTerziario/Artigianale/Industriale FEdificio pubblico od a uso pubblico F Altro …………..……...………….… a) Locale di installazione idoneo c) Aperture di ventilazione libere da ostruzioni e) Coibentazioni idonee d) Trattamento dell'acqua b) Centrale a servizio di: c) Destinazione d'uso dell'impianto F Più unità immobiliari F Raffrescamento ambienti FNon richiesto FSingola unità immobiliare FRiscaldamento ambienti F Assente e) Superficie riscaldata/raffrescata …………………….. FAddolcimento FCond. Chimico f) Consumi ……… (kWh/anno) F Si F No F NC F Si F No F NC F Si F No F NC FFiltrazione 3. VERIFICA LOCALE b) Dimensioni aperture di ventilazione adeguate d) Linee elettriche idonee 4. STATO DELLA DOCUMENTAZIONE F Si F No a) Libretto impianto presente FIsolamento rete di distribuzione b) Interventi atti a migliorare il rendimento energetico c) Stima del dimensionamento del/i generatori F Si F No F Si F No d) Libretti uso e manutenzione generatori/impianto presenti 5. INTERVENTI DI MIGLIORAMENTO ENERGETICO FAdozione generatori a più gradini o a regolazione continua FAdozione di sistemi di regolazione programmbili su più livelli di temperatura c) Dich. di conformità/rispondenza presente a) Check-list b) Libretto di impianto compilato in tutte le parti F Si F No F Si F No F NC F Si F No F NC FIsolamento canali di distribuzione FNon sono stati individuati interventi economicamente convenienti FSi allega relazione di dettaglio FSi rimanda a relazione di dettaglio successiva FValutazione non eseguita, motivo: …………………………………………………………………. FDimensionamento corretto FNon controllabile FDimensionamento non corretto FSi rimanda a relazione di dettaglio successiva – 80 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Foglio n° ….…. di .……. Catasto impianti/codice …….………...… Data della verifica …...…....……… N° ……… 6. GENERATORE b) Generatore a) Data realizzazione impianto N…………. di ………. F Acqua F Aria F Altro……… c) Data installazione gen. d) Fluido termovettore e) Tipologia gruppo frigo f) Costruttore generatore FAssorbimento per rec. calore g) Modello generatore FAssorbimento a fiamma diretta, comb. ……… h) Matricola generatore FCiclo compress. motore elettrico o endotermco i) N° circuiti j) Dati nominali Pot. frigorifera in raffrescamento …….(kW) ; Pot. termica in riscaldamento …… (kW) 7. MANUTENZIONI a) Operazioni di controllo e manutenzione: Frequenza …………… Ultima manutenzione prevista effettuata b) Rapporto di controllo tecnico Presente F Si F No F Sì F No Data:…………… Con: FOsservazioni FRaccomandazioni FPrescrizioni 8. MISURAZIONI F Riscaldamento F Raffrescamento a) Circuito N. …… di ……. b) Prova eseguita in modalità c) Valori misurati Surriscald. (°C) Sottoraffredd. (°C) T condens. (°C) T evapor (°C) T ing. lato est. (°C) T usc. lato est. (°C) T ing. lato utenze (°C) T usc. lato utenze (°C) 9. RISULTATI DELL'ISPEZIONE F Sì F No b) L'impianto rispetta quanto previsto ai punti del presente rapporto: a) L'impianto rispetta la normativa? (relativamente al DPR 74/2013 e DGR 3965/2015 e ss.mm.ii.) F 7.a 10. OSSERVAZIONI DELL'ISPETTORE 11. PRESCRIZIONI DELL'ISPETTORE Codici elenco non conformità …… ….; ………..; ………..; ………..; ………..; ………..; ………..; ………..; 12. DICHIARAZIONI DEL RESPONSABILE IMPIANTO RESPONSABILE IM PIANTO O SUO DELEGATO PER RICEVUTA …………………………………………………………. L'ISPETTORE ………………………………………… Bollettino Ufficiale – 81 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 1C - Rapporto di ispezione per impianti da teleriscaldamento VERIFICA DELLO STATO DI MANUTENZIONE ED ESERCIZIO DEGLI IMPIANTI TERMICI - SCAMBIATORI - STAGIONE 2___ - 2___ (ai sensi del DPR 74/2013 e DGR 3965/2015 e loro successive modifiche ed integrazioni) Foglio n° 1 di ……….. 1. DATI GENERALI a) Catasto impianti/codice ……..……...…. d) Dichiarato Si F1RF b) Data ispezione …………….…..…. N° ..… c) Ispettore/estremi qualifica ……………………...…… e) N° dichiarazione ………………...…… Comune f) Data dichiarazione ……………….…….....………… Località g) UBICAZIONE: Indirizzo Scala Piano Dati catastali: Sezione ……………; Foglio………………….; Particella……………………………; Subalterno ……………………………………… h) Delegato : k) Proprietario Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax Ragione sociale m) Amministratore l) T.R. / Manutentore j) Occupante Cognome e nome Indirizzo i) Responsabile impianto: Occupante F Terzo responsabile (manutentore) F Cognome e nome Indirizzo Comune Telefono Fax Proprietario/i FAmministratoreF Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax 2. DESTINAZIONE a) Destinazione prevalente dell'immobile FResidenziale b) Centrale a servizio di: c) Destinazione d'uso dell'impianto FSingola unità immobiliareFRiscaldamento ambienti d) Alimentazione FAcqua calda FEdificio pubblico od a uso pubblico e) Superficie riscaldata …………………….. FVapore FTerziario/Artigianale/Industriale F Altro …………..……...………….… riscaldamento e) Trattamento dell'acqua produzione ACS FAcqua surriscaldata FAltro ……..…….……… f) Consumi ……… (kWht/anno) 3. VERIFICA LOCALE F Si F No F NC b) Stato delle coibentazioni idoneo a) Locale installazione idoneo c) Linee elettriche idonee F Produzione di acqua calda sanitaria F Più unità immobiliari F Si F No F NA FNon Richiesto FNon Richiesto d) Assenza perdite dal circuito idraulico FAssente FAssente F Filtrazione F Filtrazione F Addolcimento F Addolcimento F Si F No F NC 4. STATO DELLA DOCUMENTAZIONE F Si F No a) Libretto impianto presente F Si F No c) Dich. di conformità/rispondenza presente F Si F No F NA f) Pratica INAIL (ISPESL) presente ove richiesta a) Check-list b) Libretto di impianto compilato in tutte le parti d) Libretti uso e manutenzione generatori/impianto presenti F Si F No F Si F No 5. INTERVENTI DI MIGLIORAMENTO ENERGETICO FAdozione valvole termostatiche su corpi scaldanti FVerifica coerenza tra parametri curva climatica impostati su centralina e valori temp. Amb. FVerifica presenza pertite acqua b) Interventi atti a migliorare il rendimento energetico c) Stima del dimensionamento del/i generatori F Si F No F NC FCond. chimico FCond. chimico FInstallazione adeguato involucro di coibentazione scambiatore FNon sono stati individuati interventi economicamente convenienti FSi allega relazione di dettaglio FSi rimanda a relazione di dettaglio successiva FValutazione non eseguita, motivo: …………………………………………………………………. FDimensionamento corretto FNon controllabile FDimensionamento non corretto FSi rimanda a relazione di dettaglio successiva – 82 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Foglio n° ….…. di .……. Catasto impianti/codice …….………...… Data della verifica …...…....……… N° ……… 6. GENERATORE b) Scambiatore a) Data realizzazione impianto N…………. di ………. F Acqua F Vapore F Altro… c) Data installazione scamb. d) Fluido termovettore e) Costruttore scambiatore f) Modello scambiatore g) Matricola scambiatore h) Pot. termica nominale (kW) a) Operazioni di controllo e manutenzione: b) Rapporto di controllo tecnico 7. MANUTENZIONI Ultima manutenzione prevista effettuata Frequenza …………….. Presente F Si F No F Sì F No Data:…………… Con: FOsservazioni FRaccomandazioni FPrescrizioni 8. MISURAZIONI - Modulo tetmico N. …… di ……. a) Valori misurati T esterna (°C) T mandata secondario (°C) Portata fluido primario (m3/h) T ritorno primario (°C) Pot. termica (kW) T mandata primario (°C) T ritorno secondario (°C) a) Potenza compatibile con i dati di progetto F Sì b) L'impianto rispetta la normativa? 9. RISULTATI DELL'ISPEZIONE F Sì F No (relativamente al DPR 74/2013 e DGR 3965/2015 e ss.mm.ii.) F No c) L'impianto rispetta quanto previsto ai punti del presente rapporto: F 7.a F 9.a 10. OSSERVAZIONI DELL'ISPETTORE 11. PRESCRIZIONI DELL'ISPETTORE Codici elenco non conformità: …… ….; ………..; ………..; ………..; ………..; ………..; ………..; ………..; 12. DICHIARAZIONI DEL RESPONSABILE IMPIANTO RESPONSABILE IM PIANTO O SUO DELEGATO PER RICEVUTA …………………………………………………………. L'ISPETTORE ………………………………………… Bollettino Ufficiale – 83 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 1D - Rapporto di ispezione per impianti cogenerativi VERIFICA DELLO STATO DI MANUTENZIONE ED ESERCIZIO DEGLI IMPIANTI TERMICI - COGENERATORI - STAGIONE 2___ - 2___ (ai sensi del DPR 74/2013 e DGR 3965/2015 e loro successive modifiche ed integrazioni) Foglio n° 1 di ……….. 1. DATI GENERALI a) Catasto impianti/codice ……..……...…. d) Dichiarato Si F1RF b) Data ispezione …………….…..…. N° ..…..… c) Ispettore/estremi qualifica ……………………...…… e) N° dichiarazione ………………...…… Comune f) Data dichiarazione ……………….…….....………… Località g) UBICAZIONE: Indirizzo h) Delegato : Scala Piano Dati catastali: Sezione ……………; Foglio………………….; Particella……………………………; Subalterno ……………………………………… Cognome e nome Indirizzo Occupante F Terzo responsabile (manutentore) F k) Proprietario Ragione sociale Cognome e nome Indirizzo Comune Telefono Proprietario/i FAmministratoreF Ragione sociale Cognome e nome Indirizzo Comune Telefono Fax Fax Ragione sociale Ragione sociale m) Amministratore l) T.R. / Manutentore j) Occupante i) Responsabile impianto: Cognome e nome Indirizzo Comune Telefono Fax Cognome e nome Indirizzo Comune Telefono Fax 2. DESTINAZIONE a) Destinazione prevalente dell'immobile FResidenziale b) Centrale a servizio di: c) Destinazione d'uso dell'impianto FSingola unità immobiliare FRiscaldamento ambienti d) Combustibile FGas naturale FEdificio pubblico od a uso pubblico e) Superficie riscaldata …………………….. FGasolio FTerziario/Artigianale/Industriale F Altro …………..……...………….… F Più unità immobiliari f) Consumi ……… (m 3/anno) ………. (kg/anno) ……… (l/anno) F Si F No F NC a) Locale installazione idoneo F Si F No F NA c) Sistema di ventilazione sufficiente F Si F No F NA e) Cartellonistica prevista presente g) Assenza perdite combustibile (esame visivo) h) Trattamento dell'acqua F Si F No F NC F Si F No F Si F No c) Dich. di conformità/rispondenza presente F Si F No F NA e) C.P.I. presente ove richiesto FGPL FAltro ……..…….……… 3. VERIFICA LOCALE F Si F No F NC b) Linee elettriche idonee F Si F No F NC d) Sistema evacuazione fumi idonea (esame visivo) F Si F No F NA f) Mezzi estinzione incendi presenti e revisionati FNon Richiesto FAssente F Filtrazione 4. STATO DELLA DOCUMENTAZIONE a) Libretto impianto presente a) Check-list F Produzione di acqua calda sanitaria F Addolcimento FCond. chimico F Si F No b) Libretto di impianto compilato in tutte le parti d) Libretti uso e manutenzione generatori/impianto presenti f) Pratica INAIL (ISPESL) presente ove richiesta F Si F No F Si F No F NA 5. INTERVENTI DI MIGLIORAMENTO ENERGETICO FAdozione valvole termostatiche su corpi scaldanti FIsolamento della rete di distribuzione nei locali non riscaldati FIntroduzione di un sistema di trattamento acqua FSostituzione sistema regolazione on/off con uno programmabile FNon sono stati individuati interventi economicamente convenienti b) Interventi atti a migliorare il rendimento energetico c) Stima del dimensionamento del/i generatori FSi allega relazione di dettaglio FSi rimanda a relazione di dettaglio successiva FValutazione non eseguita, motivo: …………………………………………………………………. FDimensionamento corretto FNon controllabile FDimensionamento non corretto FSi rimanda a relazione di dettaglio successiva – 84 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Foglio n° ….…. di .……. Catasto impianti/codice …….………...… Data della verifica …...…....……… N° ……… 6. GENERATORE b) Data installazione cogen. a) Data realizzazione impianto c) Cogeneratore d) Fluido termovettore e) Costruttore f) Pot. el. nom. morsetti (kW) g) Modello h) Pot. ass. con il combustibile (kW) i) Matricola j) Pot. termica nominale (kW) N…………. di ………. F Acqua F Aria F Altro……… k) Pot. term. a piena potenza con by-pass fumi aperto (kW) 7. MANUTENZIONI a) Operazioni di controllo e manutenzione: Frequenza …………….. Ultima manutenzione prevista effettuata F Sì F No Data:…………… b) Rapporto di controllo tecnico Presente F Si F No T aria comburente (°C) 8. MISURAZIONI - Modulo cogen N. …… di ……. a) Valori misurati T acqua in uscita (°C) T acqua in ingresso (°C) T acqua motore (solo m.c.i.) (°C) Pot. ai morsetti generatore (kW) Con: FOsservazioni FRaccomandazioni FPrescrizioni T fumi a valle scamb. (°C) F Sì T fumi a monte scamb. (°C) 9. RISULTATI DELL'ISPEZIONE F No b) L'impianto rispetta quanto previsto ai punti del presente rapporto: a) L'impianto rispetta la normativa? (relativamente al DPR 74/2013 e DGR 3965/2015 e ss.mm.ii.) F 7.a 10. OSSERVAZIONI DELL'ISPETTORE 11. PRESCRIZIONI DELL'ISPETTORE Codici elenco non conformità: …… ….; ………..; ………..; ………..; ………..; ………..; ………..; ………..; 12. DICHIARAZIONI DEL RESPONSABILE IMPIANTO RESPONSABILE IM PIANTO O SUO DELEGATO PER RICEVUTA …………………………………………………………. L'ISPETTORE ………………………………………… Bollettino Ufficiale – 85 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 2 – Modello di Libretto di impianto ,OPRGHOORHODERUDWRFRQWLHQHWXWWHOHLQIRUPD]LRQLSUHYLVWHGDJOLDOOHJDWLDO'0IHEEUDLRDOOHTXDOLVRQRVWDWHDJJLXQWH LQIRUPD]LRQLFKH5HJLRQH/RPEDUGLDULWLHQHIRQGDPHQWDOLULVSHWWRDLSURSULVLVWHPLLQIRUPDWLYL ,OPRGHOORTXLULSRUWDWRHQWUDLQYLJRUHDSDUWLUHGDODJRVWR ,OPDQXWHQWRUHDOO¶DWWRGHOODSULPDPDQXWHQ]LRQHVXFFHVVLYDDOODGDWDGLHQWUDWDLQYLJRUHqWHQXWRDFRPSLODUHLOQXRYROLEUHWWR GLLPSLDQWRDFXLGHYHHVVHUHDOOHJDWRLOYHFFKLROLEUHWWR ,O OLEUHWWR GHYH HVVHUH DJJLRUQDWR DG RJQL PDQXWHQ]LRQH UHODWLYDPHQWH DOOH VH]LRQL H ,O PDQXWHQWRUH JDUDQWLVFH OD FRUULVSRQGHQ]DWUDTXDQWRULSRUWDWRVXOOLEUHWWRGLLPSLDQWRHTXDQWRSUHVHQWHQHOUDSSRUWRGLSURYDHVXOFDWDVWR&85,7 'LVHJXLWRVLULSRUWDLOPRGHOORGLQXRYROLEUHWWRGLLPSLDQWRRUJDQL]]DWRLQVFKHGHFRPHGDHOHQFR /LEUHWWRGLLPSLDQWRFRVWLWXLWRGDOOHVHJXHQWLVH]LRQL 6FKHGDLGHQWLILFDWLYDGHOO¶LPSLDQWR 7UDWWDPHQWRDFTXD 1RPLQDGHOWHU]RUHVSRQVDELOHGHOO¶LPSLDQWRWHUPLFR *HQHUDWRUL 6LVWHPLGLUHJROD]LRQHHGLFRQWDELOL]]D]LRQH 6LVWHPDGLGLVWULEX]LRQH 6LVWHPDGLHPLVVLRQH 6LVWHPDGLDFFXPXOR $OWULFRPSRQHQWLGHOO¶LPSLDQWR ,PSLDQWRGL9HQWLOD]LRQHPHFFDQLFDFRQWUROODWD 5LVXOWDWLGHOODSULPDYHULILFDHGHOOHYHULILFKHSHULRGLFKH ,QWHUYHQWLGLFRQWUROORGLHIILFLHQ]DHQHUJHWLFD 5LVXOWDWLGHOOHLVSH]LRQLHIIHWWXDWHGDOO¶DXWRULWjFRPSHWHQWH 5HJLVWUD]LRQHGHLFRQVXPLQHLYDULHVHUFL]L 6XO SRUWDOH ZHE VRQR SXEEOLFDWL D FXUD GL ,QIUDVWUXWWXUH /RPEDUGH 6S$ L PDQXDOL GL FRPSLOD]LRQH D EHQHILFLR GHL GLYHUVL VRJJHWWLFKHRSHUDQRVXO&DWDVWR – 86 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 87 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 88 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 89 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 90 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 91 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 92 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 93 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 94 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 95 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 96 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 97 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 98 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 99 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 100 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 101 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 102 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 103 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 104 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 105 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 106 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 107 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 108 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 109 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 110 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 111 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 112 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 113 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 114 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 115 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 116 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 117 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 – 118 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Bollettino Ufficiale – 119 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 3 – Modelli di Rapporti di controllo. $QDORJDPHQWHDOPRGHOORHODERUDWRSHULOOLEUHWWRGLLPSLDQWRDQFKHLUDSSRUWLGLFRQWUROORYHQJRQRUHFHSLWLFRQWHQHQGRWXWWHOH LQIRUPD]LRQLSUHYLVWHGDJOLDOOHJDWLDO'0IHEEUDLRDOOHTXDOLVRQRVWDWHDJJLXQWHLQIRUPD]LRQLFKH5HJLRQH/RPEDUGLD ULWLHQHIRQGDPHQWDOLULVSHWWRDLSURSULVLVWHPLLQIRUPDWLYL ,PRGHOOLTXLULSRUWDWLHQWUDQRLQYLJRUHDSDUWLUHGDODJRVWR'DWDOHGDWDLOPDQXWHQWRUHqWHQXWRDFRPSLODUHLQXRYL PRGHOOLLQUHOD]LRQHDOODWLSRORJLDGLLPSLDQWRVRWWRSRVWRDPDQXWHQ]LRQH 'LVHJXLWRVLULSRUWDQRLPRGHOOLGHLQXRYL5DSSRUWLGLFRQWUROORFRPHGDHOHQFR 7LSR$±*UXSSL7HUPLFL 7LSR%±$SSDUHFFKLDELRPDVVD 7LSR±*UXSSL)ULJR 7LSR±6FDPELDWRUL 7LSR±&RJHQHUDWRUL 6XO SRUWDOH ZHE VRQR SXEEOLFDWL D FXUD GL ,QIUDVWUXWWXUH /RPEDUGH 6S$ L PDQXDOL GL FRPSLOD]LRQH D EHQHILFLR GHL GLYHUVL VRJJHWWLFKHRSHUDQRVXO&DWDVWR – 120 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 3A - Rapporto di controllo per Gruppi Termici Bollettino Ufficiale – 121 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 3B - Rapporto di controllo per Gruppi Termici a biomassa – 122 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 3C - Rapporto di controllo per Gruppi Frigo / Pompe di Calore Bollettino Ufficiale – 123 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 3D - Rapporto di controllo per Scambiatori – 124 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 3E - Rapporto di controllo per Cogeneratori / Trigeneratori Bollettino Ufficiale – 125 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 5 - Modelli di presentazione. 4XDORUD O¶$XWRULWj &RPSHWHQWH ULFKLHGHVVH FRSLD FDUWDFHD GHOOH 'LFKLDUD]LRQL GL $YYHQXWD 0DQXWHQ]LRQH OD GLWWD GL PDQXWHQ]LRQHXWLOL]]DLOVHJXHQWHPRGHOORGLGLVWLQWDJHQHUDELOHDWWUDYHUVRORVWUXPHQWRLQIRUPDWLYRGL&DWDVWRDVHJXLWRGHOOD UHJLVWUD]LRQHGHOOH'LFKLDUD]LRQLGL$YYHQXWD0DQXWHQ]LRQH ,OSUHVHQWHPRGHOORSXzHVVHUHXWLOL]]DWRDQFKHSHUODFRQVHJQDGHOOH'LFKLDUD]LRQLGL$YYHQXWD0DQXWHQ]LRQHDO&$,7FKHYLHQH LQFDULFDWRGHOODUHJLVWUD]LRQHD&DWDVWR DISTINTA DI PRESENTAZIONE DELLE DICHIARAZIONI DI AVVENUTA MANUTENZIONE $XWRULWj&RPSHWHQWHR&$,7GHVWLQDWDULRGHOOD'LVWLQWDBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 3HULRGRGLULIHULPHQWRGDOBBBBBBBBDOBBBBBBBB 6RJJHWWRSUHVHQWDQWH Data controllo BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Codice Impianto Data inserimento* Responsabile Impianto 1XPHUR'$0BBBB Comune Indirizzo Fascia Potenza 'DWDFRQVHJQD 1RQFRPSLODUHLQFDVRGLFRQVHJQDDO&$,7GDSDUWHGHO0DQXWHQWRUH,QVWDOODWRUH – 126 – Bollettino Ufficiale Serie Ordinaria n. 53 - 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TUTELA DEI DATI PERSONALI ,OFRPPDGHOO¶DUWLFRORqRS]LRQDOHSHUUHQGHUORYDOLGRLOFRPPLWWHQWHHO¶LQFDULFDWRGHOUXRORGLWHU]RUHVSRQVDELOHGHYRQR DSSRUUHOHSURSULHVLJOHDOODWRGHOFRPPDVWHVVR Bollettino Ufficiale – 131 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 $LVHQVLGHO'/JVLOFRPPLWWHQWHDXWRUL]]D DSSDOWDWRUHDGXWLOL]]DUHLSURSULGDWLSHUVRQDOLXQLFDPHQWHDL ILQLGHOO DGHPSLPHQWRGHOSUHVHQWHFRQWUDWWR ,/&200,77(17( ,/7(5=25(63216$%,/( $LVHQVLGHJOLDUWWHGHOFRGLFHFLYLOHOHSDUWLGLFKLDUDQRGLDSSURYDUHVSHFLILFDPHQWHOHVHJXHQWLFODXVROH $UW2EEOLJKLGHOWHU]RUHVSRQVDELOH $UW±&RPSLWLGHOWHU]RUHVSRQVDELOH $UW±2EEOLJKLGHOFRPPLWWHQWH $UW±'XUDWDGHOFRQWUDWWRHULVROX]LRQH $UW±3UH]]LGHLPDWHULDOLHTXRWD]LRQLGHOODPDQRGRSHUD $UW±&RQWURYHUVLH ,/&200,77(17( ,/7(5=25(63216$%,/( – 132 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 7 - Comunicazione di responsabilità per impianti termici Al Comune / Alla Provincia di ..…….…..………………………………. Ente locale responsabile dei controlli D.lgs 192/05 e s.m.i. Ufficio Energia/Ambiente Via ………………………..….…………..……………………….. Città ………………………………………………………………. Oggetto: comunicazione di responsabilità dell’impianto. ,OVRWWRVFULWWR«««««««««««««««««««««««««««««««««««««««««««««««« /HJDOHUDSSUHVHQWDQWHGHOOD'LWWD«««««««««««««««««««««««««««««««««««««««« LVFULWWDDOOD&&,$$GL«««««DOQXPHUR««DELOLWDWDDGRSHUDUHSHUJOLLPSLDQWLGLFXLDOOHOHWWHUH DEFGHIJGHOO¶DUWLFRORGHO'0 LQSRVVHVVRGHOO¶XOWHULRUHUHTXLVLWRGL FHUWLILFD]LRQHGHO6LVWHPD4XDOLWjDLVHQVLGHOODQRUPD81,,62(1«««««««««««««««««««««« $OWUR««««««««««««««««««««««««««««««««««««««««««««««« Comunica GLDYHUDVVXQWRO¶LQFDULFRGLWHU]RUHVSRQVDELOHGDOODGDWDGHO««««««««««««««««««««««««««« GLQRQHVVHUHSLWHU]RUHVSRQVDELOHGDO«««««««VFDGHQ]DLQFDULFRSHUUHYRFDGHOO¶LQFDULFRSHUGLPLVVLRQL LQGLFDUHODPRWLYD]LRQHLQFDVRGLUHYRFDRGLPLVVLRQH«««««««««««««««««««««««««««««««« ,PSLDQWRGHVWLQDWRDFOLPDWL]]D]LRQHLQYHUQDOHSURGX]LRQHFHQWUDOL]]DWDGL$&6FOLPDWL]]D]LRQHHVWLYD FDWDVWRLPSLDQWLFRGLFH«««««««««««««««««««««««««««««««««««««««««««« VLWRLQYLD««««««««««««««««««««««««&RPXQHGL««««««««««««««««««« GLSURSULHWjGL««««««««««««««««««««««««««««««««««««««««««««««« GLSRWHQ]DWHUPLFDGHOIRFRODUHRXWLOHLQFDVRGLVRWWRVWD]LRQLWHOHULVFDOGDPHQWRRSRPSHGLFDORUHFRPSOHVVLYDQRPLQDOHGL««««N: Consapevole che la dichiarazione mendace e la falsità in atti costituiscono reati ai sensi dell’art. 76 del D.P.R. 445/00 e comportano l’applicazione della sanzione penale, ai fini dell’assunzione dell’incarico di terzo responsabile il sottoscritto dichiara: di non essere fornitore di energia per il medesimo impianto; di essere fornitore di energia per il medesimo impianto. ,QROWUHFRQVDSHYROHGLPDQWHQHUHOHUHVSRQVDELOLWjDVVXQWHGLFKLDUDGLGHOHJDUHDOFXQHDWWLYLWjGLSURSULDFRPSHWHQ]DFRPHGLVHJXLWRLQGLFDWR DWWLYLWj««««««««««««««««««VRJJHWWRGHOHJDWR««««««««««««««««««««««« DWWLYLWj««««««««««««««««««VRJJHWWRGHOHJDWR««««««««««««««««««««««« DWWLYLWj««««««««««««««««««VRJJHWWRGHOHJDWR««««««««««««««««««««««« ULSRUWDUHUDJLRQHVRFLDOHHFRGLFHUHJLVWUD]LRQHD&85,7 )LUPD««««««««««««««««««««««««««««««««««««««««««««««««««« 5DJLRQHVRFLDOHGHOOD'LWWD««««««««««««««««««««««««««««««««««««««««««« 1RPHHFRJQRPHGHOOHJDOHUDSSUHVHQWDQWH««««««««««««««««««««««««««««««««««««« ,QGLUL]]R««««««««««««««««««««««««««««««««««««««««««««««««««« 7HOHIRQR«««««««««««««&HOOXODUH«««««««««««««««)D[«««««««««««««« (PDLO««««««««««««««««««««««««««««««««««««««««« $FXUDGHOFRPPLWWHQWHGHOO¶LQFDULFRGLWHU]RUHVSRQVDELOH 1RPLQDWLYRGHOIRUQLWRUHGLHQHUJLD««««««««««««««««««««««««««««««««««««««« 1RPHHFRJQRPH5DJLRQHVRFLDOHGHOFRPPLWWHQWH«««««««««««««««««««««««««««««««««« )LUPDGHOFRPPLWWHQWH«««««««««««««««««««««««««««««««««««««««««««««« 1HOOHFRPXQLFD]LRQLGLILQHUHVSRQVDELOLWjODILUPDGHO&RPPLWWHQWHqREEOLJDWRULDVRORLQFDVRGLUHYRFDPHQWUHqIDFROWDWLYDLQFDVRGL VFDGHQ]DQDWXUDOHRGLPLVVLRQL Bollettino Ufficiale – 133 – Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 8 - Modello dichiarazione per Amministratori di Condominio Al Comune / Alla Provincia di …………………………..…….…..……………………. Ente locale responsabile dei controlli D.lgs 192/05 e s.m.i. Ufficio Energia/Ambiente Via ………………………..….…………..…………….. Città ……………………………………………………. Oggetto: comunicazione di assunzione del ruolo di responsabile per l’esercizio e la manutenzione degli impianti termici in qualità di amministratore di condominio (art.7 D.lgs 192/05 e s.m.i.). ,OVRWWRVFULWWR«««««««««««««««««««««««««««««««««««««« ,QTXDOLWjGL«««««««««««««««««««««««««««««««««««««« Comunica GLDYHUDVVXQWRO¶LQFDULFRGL$PPLQLVWUDWRUHGHO&RQGRPLQLR««««««««VLWRLQ«««««« ««««««««««««««««««««««««GDOODGDWDGHO«««««««««««««« GLQRQHVVHUHSL$PPLQLVWUDWRUHGHO&RQGRPLQLR««««««««VLWRLQ«««««««««« ««««««««««««««««««««««««GDOODGDWDGHO««««««««««««« di essere responsabile per l’esercizio e la manutenzione dell’impianto di : di non essere responsabile per l’esercizio e la manutenzione dell’impianto di : FOLPDWL]]D]LRQHLQYHUQDOHSURGX]LRQHFHQWUDOL]]DWDGL$&6FOLPDWL]]D]LRQHHVWLYD FDWDVWRLPSLDQWLFRGLFH««««««««««««««««««««««««««««««««««« VLWRLQYLD«««««««««««««««««««&RPXQHGL«««««««««««««««« GLSURSULHWjGL«««««««««««««««««««««««««««««««««««««« FRPSRVWRGDLVHJXHQWLJHQHUDWRULGLFDORUH *SRWHQ]DQRPLQDOHGL«««««N:&RPEXVWLELOH«««««««««««« *SRWHQ]DQRPLQDOHGL«««««N:&RPEXVWLELOH«««««««««««« *SRWHQ]DQRPLQDOHGL«««««N:&RPEXVWLELOH«««««««««««« *SRWHQ]DQRPLQDOHGL«««««N:&RPEXVWLELOH«««««««««««« )LUPD««««««««««««««««««««««««««««««««««««««««« 5DJLRQHVRFLDOHGHOOD'LWWD««««««««««««««««««««««««««««««««« 1RPHHFRJQRPHGHOOHJDOHUDSSUHVHQWDQWH««««««««««««««««««««««««««« ,QGLUL]]R«««««««««««««««««««««««««««««««««««««««« 7HOHIRQR««««««««&HOOXODUH«««««««««)D[«««««««««««««««« (PDLO««««««««««««««««««««««««««««««««««««««««« 1RPLQDWLYRGHOIRUQLWRUHGLHQHUJLD«««««««««««««««««««««««««««««« 1RPLQDWLYRGHOO¶HYHQWXDOH7HU]R5HVSRQVDELOH««««««««««««««««««««««««« – 134 – Bollettino Ufficiale Serie Ordinaria n. 53 - Mercoledì 30 dicembre 2015 Allegato 9 – Dichiarazione ai sensi dell’art. 284 del D. 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