Report form - Requalification by External Visual Inspection

Company:

Facility Location:

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Date: Month Year

Responsible Manager: (Signature)

Cylinder Identification Protective Coating
Serial Number Identifying Symbol Specification
and Service
Pressure
Manufacturer Date of Mfg. (mm/yy) Type Condition
110506 123 Inc. DOT-4BA240 M#### 01/90 Paint Good
296087 TDG Cyl. TC-4BWM16 M#### 03/02 Galvanized Fair
Cylinders Inspected for
Serial Number Corrosion and Pitting Dents Cuts, Digs and Gouges Leaks Fire Damage Bulges Neck Defects Attachments
110506 checked checked checked checked checked checked checked checked
296087 SC** checked checked checked checked checked checked checked
Disposition
Serial Number Disposition Date Inspected (dd/mm/yy) Inspector Initals
110506 OK 01-06-2012 TC
296087 SC 01-06-2012 TC

Disposition code: OK - Return to Service
SC - Scrap (Condemned)

Remarks: **Cylinder serial number 296087 - Condemned due to excessive corrosion

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