Total Price
Above prices do not include applicable sales taxes
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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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