# 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:**  
<u>CONDUIT SIZE:</u>  
**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