MINI-SPLIT FORM
Refrigerant Charge Verification
TECHNICIAN
JOB #
CUSTOMER INFO
CUSTOMER NAME
First Name
Last Name
ADDRESS
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
MINI-SPLIT DATA
TIME/DATE OF VERIFICATION
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
OUTSIDE TEMPERATURE
MINIMUM REQUIRED SYSTEM AIRFLOW RATE (CFM)
INITIAL VACUUM LEVEL AND TIME
FINAL VACUUM LEVEL AND TIME
CONDENSER MODEL NUMBER
STANDARD CHARGE (LBS., OZS.)
STANDARD LIQUID LINE LENGTH AND DIAMETER
STANDARD EVAPORATOR COIL SIZE (TONS)
CHARGE ADJUSTMENT FACTOR (OUNCES/FOOT)
INSTALLED LIQUID LINE LENGTH (FEET)
INSTALLED LIQUID LINE DIAMETERS (TYP. 3/8”)
INSTALLED EVAPORATOR COIL SIZE (TONS)
CHARGE CORRECTION CALCULATION (LBS., OZS.)
INITIAL REFRIGERANT CYLINDER WEIGHT
FINAL REFRIGERANT CYLINDER WEIGHT
INSTALLED REFRIGERANT WEIGHT
FINISH
Submit
Should be Empty: