VCI Form

VCI Form
Store or Customer Cylinder *

Store Customer
Date of Inspection / Service *

Month Day Year
Date
SF Null Owner
Store Hidden Email
example@example.com
Visual Cylinder Inspections
OWNER *
Email
example@example.com
Customer Phone Number

Area Code Phone Number
Store Cylinder ID *
Serial No. *
First Hydro Date *

Month Day Year
Date
Most Recent Hydro *

Month Day Year
Date
Manufacturer
Next Hydro Null Calculation *
Next Visual Null Calculation *
Next Hydro Needed *

Month Day Year
Date
Next Visual Needed *

Month Day Year
Date
Size
Color
Working Pressure
Use

SCUBA SCBA Other
Type

3 AA Steel 3 AL Aluminum
Special Permit # or Specification
EXTERNAL
Evidence of Heat Damage

Yes No
Re-Paint

Yes No
Odor

Yes No
Evidence of Bulges

Yes No
Hammer Tested (steel only) Bell Tone

Yes No
Line Corrosion

Yes No
Description of exterior surface
Result

Accept Reject Condemn
INTERNAL
Pits

Yes No
Location
Estimated Depth
Amount and composition of foreign material
Description of internal surface
Result

Accept Reject Condemn
CYLINDER THREADS
Description
Crack Assessment
Eddy Current Test

Yes No N/A
Result

Accept Reject Condemn
VALVE
Dip Tube Compliant

Yes No
Burst Disk Replaced

Yes No
Number of Continuous Threads
Neck Oring Replaced

Yes No
Service Needed

Yes No
Note
Result

Accept Replace
CYLINDER CONDITION
Result

Accept Accept with notation* Reject Clean Tumble Hydro Condemn Other
Notation*
VCI Sticker Affixed

Yes No
Date

Month Day Year
Date
I certify that this inspection was done in accordance with prescribed guidlines per DOT,CGA,OSHA and PSI standards
Inspector name(print)
PSI No.
Signature

Clear
Should be Empty:

VCI Form

EXTERNAL

INTERNAL

CYLINDER THREADS

VALVE

CYLINDER CONDITION