Regulator Inspection Form

Regulator Inspection Form
Today's Date*

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Date
Store or Customer Cylinder*

StoreCustomer
Date of Inspection / Service*

MonthDayYear
Date
Store Regulator Set ID*
SF Null Owner
Store Hidden Email
example@example.com
Regulator Inspections
Make Model 1st Stage
Serial No. 1st Stage
Make Model 2nd Stage
Serial No. 2nd Stage
Make Model Octo
Serial No. Octo
Next Inspection Null Calculation*
Next Inspection Needed*

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Date
Tests 1 - 6 to be completed while unit is pressurized to at least 3000psi
Test 1: Pressurized Immersion Test. Pressurize unit, submerge and look for leaks.

PassFail
Notes
Test 2: Inter-stage Pressure (IP) Check. Check for stable pressure. IP =

PassFail
IP =
Range
Notes
Test 3: Opening Effort Primary 2nd Stage.

PassFail
Inches / Water
Range
Notes
Test 4: Primary 2nd Stage operation of knobs/venture switches. All mechanisms should operate smoothly.

PassFail
Notes
Test 5: Opening Effort Alternate 2nd Stage

PassFail
Inches / Water
Range
Notes
Test 6: Alternate 2nd Stage operation of knobs/venture switches. All mechanisms should operate smoothly.

PassFail
Notes
Test 7: 1st Stage Filter Inspection. Check for discoloration and debris.

PassFail
Notes
Test 8: Primary 2nd Stage Negative Pressure Test. Inspect mouthpiece, purge and exhaust diaphragms.

PassFail
Notes
Test 9: Alternate 2nd Stage Negative Pressure Test. Inspect mouthpiece, purge and exhaust diaphragms.

PassFail
Notes
Test 10: Hose Inspection. Inspect hoses for cracks, damage at swages, crimping or blistering.

PassFail
Notes
If regulator fails Test 1 through 6, service is required. If regulator fails 7 through 10, service is at technician’s discretion.
I certify that this inspection was done in accordance with prescribed guidlines per DOT,CGA,OSHA and PSI standards
Inspector name(print)
Signature

Clear
Date

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Date
Should be Empty:

Regulator Inspection Form

Tests 1 - 6 to be completed while unit is pressurized to at least 3000psi

If regulator fails Test 1 through 6, service is required. If regulator fails 7 through 10, service is at technician’s discretion.