# LEAK TEST RECORD

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**Client/Site:**  
**Project ID#:**  
**System:**  
**Test No.:**  
**Test Type:** Hydrostatic Pneumatic  
**Equipment ID:**  
**Applicable Code:** Hydro-Pneumatic (combo)  
In-Service

**Test Media:**  
□ Other____

**Required Test Pressure:** PSIG

|  |  |  |  | Test Boundary(Partial Test) |  |
| --- | --- | --- | --- | --- | --- |
| Drawing #/Rev# | Item/Equip/Line # | Std/Spec |  | From | To: |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
|  |  |  |  |  |  |
| Pretest Inspection Checklist |  |  | N/A | Satisfactory(init/date) | Unsatisfactory(init/date) |
| 1. Approved test media source(s) identified/located |  |  |  |  |  |
| 2. Chloride content of water verified<50 ppm(stainless and high alloy steels) |  |  |  |  |  |
| 3. Items not subjected to test pressure have been isolated from test(e.g.control valves, instruments, etc.) |  |  |  |  |  |
| 4. Equipment/piping is properly supported |  |  |  |  |  |
| 5. Blinds are proper size/thickness for pressure and correctly installed |  |  |  |  |  |
| 6. All deviations to test procedures/codes/standards have been approved and copies of approvals attached |  |  |  |  |  |
| 7. Pressure gauge/reorder ranges are>1.5and<4Xreq'd test pressure |  |  |  |  |  |
| 8. Required overpressure protection devices have been installed |  |  |  |  |  |
| 9. All required welding and NDE has been completed |  |  |  |  |  |
| 10. Temperature of equipment and test media stabilized and minimum test temperature verified. |  |  |  |  |  |

Date: Ambient temp.:  
Metal temp.:  
Test Gauge ID#:  
Calibration Due Date:  
Actual Test Pressure:  
Test Duration:

**Test Accepted:**  
QC Representative/Company  
**Test Vented, Drained, Flushed upon completion of testing:**  
Owner Representative  
Fabricator Representative/Company  
N/A

## Remarks:

Owner Representative  
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