Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Regional office No. ____

Date & time of Inspection: ____________

Date & time completed: ____________

POWER PIPING LINES INSPECTION REPORT

General Information

Name of Establishment: _______________________________________________________________

Address: ____________________________________________________________________________
Owner/Manager : _______________________________ Nature of work process:_________________
Type of Workplace (hazardous/non-hazardous: ____________________________________________

Power Piping Lines Date

Manufacturer of Brand: ______________________________ASTM Specification:_________________

Temperature Range: ___________ASA Code max. psi: __________Operating pressure: ___________
Pipe wall thickness : _____________________ Pipe line diameter:_______________________ inches
Pipe line connection : _____________________ Pipe line total equivalent length:________________
Total volume of pipeline under pressure: __________________________________________________
Contents of pipe lines: ________________________________________________________________

Inspection Proper

Pipe Line general condition (pipe, values & fittings): _________________________________________

Hydrostatic Test Application: _____________________________NDT Application: ________________

I hereby certified that this is a true report on conditions specified power piping lines and I am
recommending the issuance of its operation permit at a pressure not to exceed ______psi.

Conducted by: Evaluation Conducted by:

_______________________________ ________________________________
(Print name & signature) TSSD Chief/or as Authorized
(Print name & signature)
In the Presence of Authorized Representative:

_______________________________
(Print name & signature)

INSPECTION FEE: Php ___________

O.R. Number : ___________
Date Paid : ___________