VCI Form

VCI Form
Store or Customer Cylinder*

StoreCustomer
Date of Inspection / Service*

MonthDayYear
Date
SF Null Owner
Store Hidden Email
example@example.com
Visual Cylinder Inspections
OWNER*
Email
example@example.com
Customer Phone Number

Area CodePhone Number
Store Cylinder ID*
Serial No.*
First Hydro Date*

MonthDayYear
Date
Most Recent Hydro*

MonthDayYear
Date
Manufacturer
Next Hydro Null Calculation*
Next Visual Null Calculation*
Next Hydro Needed*

MonthDayYear
Date
Next Visual Needed*

MonthDayYear
Date
Size
Color
Working Pressure
Use

SCUBASCBAOther
Type

3 AA Steel3 AL Aluminum
Special Permit # or Specification
EXTERNAL
Evidence of Heat Damage

YesNo
Re-Paint

YesNo
Odor

YesNo
Evidence of Bulges

YesNo
Hammer Tested (steel only) Bell Tone

YesNo
Line Corrosion

YesNo
Description of exterior surface
Result

AcceptRejectCondemn
INTERNAL
Pits

YesNo
Location
Estimated Depth
Amount and composition of foreign material
Description of internal surface
Result

AcceptRejectCondemn
CYLINDER THREADS
Description
Crack Assessment
Eddy Current Test

YesNoN/A
Result

AcceptRejectCondemn
VALVE
Dip Tube Compliant

YesNo
Burst Disk Replaced

YesNo
Number of Continuous Threads
Neck Oring Replaced

YesNo
Service Needed

YesNo
Note
Result

AcceptReplace
CYLINDER CONDITION
Result

AcceptAccept with notation*RejectCleanTumbleHydroCondemnOther
Notation*
VCI Sticker Affixed

YesNo
Date

MonthDayYear
Date
I certify that this inspection was done in accordance with prescribed guidlines per DOT,CGA,OSHA and PSI standards
Inspector name(print)
PSI No.
Signature

Clear
Should be Empty:

VCI Form

EXTERNAL

INTERNAL

CYLINDER THREADS

VALVE

CYLINDER CONDITION