Refrigeration Service Report Form
Appliance ID
*
Name and circuit if applicable
Street Address Line 2
Facility
Location
Zip Code
Model
Serial Number
Date Of Repairs
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Refrigerant
*
Refrigerant Added
*
Pounds
Refrigerant Removed
Pounds
Description of Leak
Provide details of components and locations of leaks. (add photos later)Â
Repair & Verification Summary
Repair Details
Describe in detail what was repaired, if unrepaired why and recommendations.
Initial Verification Method(s)
Soap Bubble
Pressure
Vacuum
Electronic Leak Detector
Ultrasonic Leak Detector
Fluorescent Dye & Black Light
Infrared Test
Halon Gas Detection
Other
Follow-Up Verification Method(s) at operating conditions
Soap Bubble
Pressure
Vacuum
Electronic Leak Detector
Ultrasonic Leak Detector
Fluorescent Dye & Black Light
Infrared Test
Halon Gas Detection
Other
Back
Next
Photos
1
Browse Files
Drag and drop files here
Choose a file
Cancel
of
2
Browse Files
Drag and drop files here
Choose a file
Cancel
of
3
Browse Files
Drag and drop files here
Choose a file
Cancel
of
4
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photos
Â
Photo 1
Photo 2
Photo 3
Photo 4
Back
Next
Conclusion
Conclusion
*
All Repairs Complete
Repairs Not Complete (Need Return Trip)
Repairs Complete but not final verification
Appliance Mothballed
No
Yes
Lead Technician
*
First Name
Last Name
Technician Signature
Submit
Should be Empty: