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4140 Reilly Rd

Wichita Falls, TX 76305

Test Conducted By: ______________________

Customer: ________________

Report # __________________

Tag # __________________________

Drawing # _________________________

Test Results

Part # _____________________ PO #: ___________________ Date: __________

Quantity Tested: ______ PSI: ________ Duration: ______________

Pass______ Fail______

Comments:

The above mentioned employee is responsible for reading and understanding the hydrostatic test
procedure specification.

QA approved by_____________________ Date_____________

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