THERMA

1601 Las Plumas Ave. San Jose, CA. 95133 Ph: (408) 347-3400
INSTRUMENT EXAMINATION REPORT

JOB #:
DATE:
INSTRUMENT TYPE:
P. O. #:
ITEM #:
CONNECTION SIZE:
TYPE:

• o NPT
• o T.C.
• o FLG

SPECIFICATION:
CONDUIT SIZE:
SURFACE FINISH REPORT:
SURFACE FINISH:
SEAL MATERIAL:
HEAT NUMBERS:
MTR’s PROVIDED (Y/N):
CALIBERATION CERTIFICATE REQUIRED?
RECEIVED CALIBRATED RANGE:
UNITS:
SIGNAL TYPE:

• o 4-20mA (2-Wire)
• o 4-20mA (4-Wire)
• o 4-20 mA (120 VAC Powered)
• o OTHER

RESULTS:

• ACCEPTED
• REJECTED
  COMMENTS:
  (SURFACE FINISH TESTING MAP, SERIAL NUMBERS, W/DISPLAY, ETC.)

EXAMINER

Rev. 0 FN 7.002.8