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
Date
Refrigerant
*
Refrigerant Added
*
Pounds
Refrigerant Removed
Pounds
Description of Leak
Provide details of components and locations of leaks. (add photos later)
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
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Photos
1
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2
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3
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4
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Take Photos
Photo 1
Photo 2
Photo 3
Photo 4
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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
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