Measuring Devices Service Report
Enter the agent and device details, then provide service date and any remarks.
Agent Name
Please Select
Please Select
Agent 1
Agent 2
Other
Agent License Number
Please Select
Please Select
Lic #1
Lic #2
Other
Location of Device
Please Select
Please Select
Location 1
Location 2
Other
Company Name
*
Address
*
City, State, Zip
*
County
Please Select
Please Select
County 1
County 2
Other
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Device Information
Rows
Device ID (i.e., pump or check stand #)
Device Manufacturer
Model Number
Serial Number
NTEP CC Number (device or component)
Type of Device (capacity if applicable)
1
2
3
4
5
6
7
8
9
10
Remarks
Submit Report
Should be Empty: