Glenns Refrigerant Management Form

Glenns Refrigerant Management Form
Glenns WO#*
Technician Name*
Customer WO / Tracking #
Store Name & Number (if applicable)*
System Name / ID*
Date Leak Located*

MonthDayYear
Date
Date Leak Repaired

MonthDayYear
Date
Is leak repaired*

YesNo
Amount of Refrigerant Added*
Type of Refrigerant*

R22R408aR422dR507R404a (HP62)R401 (MP39)R448aOther
General area of leak*

Rack areaRefrigeration PipingWalk inCaseOther
What part / component / was leak found on? *
i.e. (txv, solenoid, valve cap, etc.)
What caused leak:

CorrosionGasket / seal failureMissing partLine breakAbuseVibration relatedBraze joint failureNormal wear / tearOther
How was leak repaired? *
i.e. (re-soldered, replaced part, retrofitted refrigerant, tightened connection, etc
Leak Detect Method*

BubblesDye InjectionElectronic / UltrasonicPressureEvacuation
2nd Leak Detect Method*

BubblesElectronic / Ultrasonicn/a
Take Photo of Leak
Upload Existing Photos of Leak

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