Vehicle Air Conditioning Refrigerant Discharge Record Form
Complete this form to document all required details for vehicle A/C refrigerant discharge events during service.
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vehicle Make and Model
*
Vehicle Year
*
Vehicle Identification Number (VIN) or Registration Number
*
Service Facility/Location
*
Reason for Refrigerant Discharge
*
A/C System Repair
Component Replacement
Leak Detection
Routine Maintenance
Other
Type of Refrigerant Discharged
*
Please Select
R-134a
R-1234yf
R-12
Other
Quantity of Refrigerant Discharged (grams)
*
Method of Discharge
*
Recovery Machine
Manual Discharge
Vented
Other
Technician Name and Certification/ID
*
Service Authorization (Supervisor/Manager Name or Signature)
*
Submit Record
Should be Empty: