Attach 2 - AF 1222.pdf

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24. LAST HYDROSTATIC TEST

DATE:

2. DATE OF INSPECTION

1. TYPE OF INSPECTION

INTERNAL AND EXTERNAL

A

VA

BOILER OR

3. INSPECTION/DELIVERY ORDER NO.

VB

INTERNAL EXTERNAL UNDER HYDROSTATIC TEST

B

PRESSURE VESSEL

INSPECTION REPORT

VC

EXTERNAL UNDER OPERATION

C

4. CONTRACT NUMBER

VD

EXTERNAL UNDER HYDROSTATIC TEST

D

VE

EXPANSION/RECEIVER TANK

E

5. INSTALLATION

6. STATE

7. ZIP CODE

9. TYPE

FIRE TUBE

CAST IRON

8. PLANT OR BLDG.

WATER TUBE

EXPANSION TANK

OTHER (Specify)

10. PLANT

MANNED

UNMANNED

11A. PRESSURE PREVIOUS INSPECTION

11B. PRESSURE THIS INSPECTION

12. USE

13A. YEAR BUILT

13B. YEAR INSTALLED

POWER

STEAM HEATING

14A. PRIMARY FUEL (Boiler) 14B. SECONDARY FUEL (Boiler)

PROCESS

STORAGE

15. DESIGN WORKING PRESSURE OR TEMPERATURE

HTHW

HEAT EXCHANGE

16. MANUFACTURER

OTHER (Specify)

17. MANUFACTURER'S RATING MBTU

18A. NATIONAL BOARD NUMBER

18B. USAF NUMBER

19. METHOD OF FIRING (Boilers)

20. SAFETY RELIEF VALVES SETTING

21. EXPLAIN IF PRESSURE CHANGED

NEW

RETEST

22. PRESSURE GAGE TESTED

YES

NO

23. PURPOSE OF HYDROSTATIC TEST

25. HYDROSTATIC TEST

DATE:

YES

NO

PSI:

PSI:

STATEMENT OF BASE CIVIL ENGINEER

26.

REPAIRS MADE SINCE LAST INSPECTION

NONE

OTHER (Specify) 27.

INTERNAL INSPECTION

DESCRIBE INSPECTION FULLY (State location of any damage or deposits, i.e., scale, grease, oil or others; any corrosion, pitting, grooving, cracking or lamination; any evidence of overheating, broken or loose items, etc.)

28.

EXTERNAL INSPECTION

CONDITION OF BOILERS VESSELS AND PLANT (Describe fully and state location of any corrosion, leakages, evidence of overheating, soot or other destructive accumulations, or safety or ASME violations, etc.)

29. SETTINGS, LININGS, SUPPORTS AND BAFFLES

INSPECTION OF SAFETY DEVICE

30. SAFETY

31. SIZE

32. TOTAL CAPACITY

33. CONDITION AND HOW TESTED

RELIEF

VALVES

NUMBER:

CFM:

BTU/HR:

LB/HR:

PRESSURE

GAGES

34.

35. CORRECTION TAKEN

(If none give reason)

36. OTHER

37. CONDITION

ITEMS

38. REGULATORS

39. CONDITION

AND

CONTROLS

40. ASME CODES

DOES PLANT COMPLY WITH CODE, WELDING, MATERIALS, CONFIGURATION, ETC?

YES

NO

PREVIOUS EDITION IS OBSOLETE.

AF IMT 1222, 19990201, V2

INSPECTOR STATEMENT

41. WAS BOILER OR VESSEL PREPARED FOR THOROUGH EXAMINATION (If NO, state what was not and why in Remarks and Recommendations of Inspector.)

DOES PLANT COMPLY WITH CODE, WELDING, MATERIALS, CONFIGURATION, ETC?

YES

NO

42. WAS BOILER ENTERED FOR THE INSPECTION (If NO, state what was not and why in Remarks and Recommendations of Inspector.)

YES

NO

REMARKS AND RECOMMENDATIONS OF THE INSPECTOR

43. LIST ALL DEFICIENCIES TO BE CORRECTED OR REPAIRED (Use a continuation sheet if necessary._)

NAME AND TITLE OF AIR FORCE REPRESENTATIVE

ACCOMPANYING INSPECTOR

44. TYPED NAME AND TITLE OF INSPECTOR

45.

46A. SIGNATURE OF INSPECTOR

46B. DATE OF SIGNATURE

46C. INSPECTOR'S NATIONAL BOARD

COMMISSION NUMBER

47.

ACTION TAKEN ON RECOMMENDATIONS

DATE AND ACTION TAKEN OR TO BE TAKEN

48. TYPED NAME, TITLE AND GRADE OF OFFICER IN CHARGE

49. SIGNATURE OF OFFICER IN CHARGE

50. DATE OF SIGNATURE

AF IMT 1222, 19990201, V2

(REVERSE)

8.2.1.3158.1.475346.466429