Leak Repair Data Form

Repair Company

Customer Company

Email

Callback Number

Job Number

Priority

Type of Quote

Operating Temperature (°F)

Design Temperature (°F)

Operating Pressure (psi)

Design Pressure (psi)

Line Material

Strongback Design Material (if applicable)

Enclosure Design Material

Please describe your intended design:

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Type of Leak or Issue

Thin Spot

Corrosion Under Insulation (CUI)

Pinhole

Hole

Crack (longitudinal)

Crack (circumferential)

Material Corrosion

Gasket Leak

Flange Bolt Failure

Description of Leak

Severity of Leak

Sealant Requirements

Perimeter Only

Void Fill Only

Perimeter and Void Fill

Type of Perimeter

Do you need strongbacking? (May change after engineering review)

Yes

No

Please enter any additional information you want to relay to the engineer:

Manufacturing Assessment Form