Glenns Refrigerant Management Form
Glenns WO#
*
Technician Name
*
Customer WO / Tracking #
Store Name & Number (if applicable)
*
System Name / ID
*
Date Leak Located
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Leak Repaired
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is leak repaired
*
Yes
No
Amount of Refrigerant Added
*
Type of Refrigerant
*
R22
R408a
R422d
R507
R404a (HP62)
R401 (MP39)
R448a
Other
General area of leak
*
Rack area
Refrigeration Piping
Walk in
Case
Other
What part / component / was leak found on?
*
i.e. (txv, solenoid, valve cap, etc.)
What caused leak:
Corrosion
Gasket / seal failure
Missing part
Line break
Abuse
Vibration related
Braze joint failure
Normal wear / tear
Other
How was leak repaired?
*
i.e. (re-soldered, replaced part, retrofitted refrigerant, tightened connection, etc
Leak Detect Method
*
Bubbles
Dye Injection
Electronic / Ultrasonic
Pressure
Evacuation
2nd Leak Detect Method
*
Bubbles
Electronic / Ultrasonic
n/a
Take Photo of Leak
Upload Existing Photos of Leak
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