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REFRIGERANT COMPLIANCE REPORT (to be submitted whenever refrigerant is used)
Service Order: | Work Date: |
Job Site Name | Contact Name | ||
Street Address | PO | ||
City |
Unit No | Manufacturer Name | ||
Model No | Serial Number | ||
Equipment Type | Refrigerant Type |
Leak Location | |
Leak Test Procedure | |
Was the leak repaired? | |
If the repair is for industrial refrigeration equipment or is on a United States Federally owned building, then a 30 day follow-up test is required to validate the system is no longer leaking. |
30 Day follow-up test is APPROVED |
30 Day follow-up test is NOT APPROVED |
/ | X | / | X | = | ||||||
Pounds of refrigerant added | full unit charge, in pounds | days per year | days since refrigerant was last added | % annual leak rate |
Recoverery Unit Manufacturer | Model | Serial Number | |
Recovered Refrigerant Amount | lbs. | oz. | |
Acid Test Results? | Moisture Test Results? | ||
Refrigerant Status? | Comments |
Recovered refrigerant used? | lbs. | Reclaimed / Disposed of refrigerant? | lbs. | ||
NEW refrigerant used? | lbs. | Recycled refrigerant used? | lbs. | ||
Refrigerant furnished by? | Contractor | Client | Other |
Note: If deficiencies or discrepancies noted are not corrected, you may be in violation of the Federal Clean Air Act, Section 608. Refer to https://www.epa.gov/ozone for more details. |
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