Scuba Regulator Service Form | UTD Scuba Diving

Owner Name*

First Last

Owner Email*

First Stage Make/Model

First Stage Serial Number

Second Stage Make/Model

Second Stage Serial Number

Overall appearance; dry rot, corrosion, cuts, nicks, etc.

Okay
Requires Service

All hoses checked for cracks, corrosion

Okay
Requires Service

Pressure check 1st stage to manufacturer specs

Okay
Requires Service

No leaks or free flow?

Okay
Requires Service

Ease of breathing

Okay
Requires Service

Purge flow rate

Okay
Requires Service

SPG is accurate? No leak at swivel?

Okay
Requires Service

First Stage Intermediate Pressure

Second Stage Cracking Pressure

First Stage Service Notes

Second Stage Service Notes

Other Comments

First Stage – I certify that the above first stage regulator and any attached accessories meet manufacturer's specifications and are approved for return to service.*

Approved
Not Approved
Other

First Stage – if "Other," explain:

Second Stage – I certify that the above second stage regulator and any attached accessories meet manufacturer's specifications and are approved for return to service.*

Approved
Not Approved
Other

Second Stage – if "Other," explain:

Technician Name*

Technician Email*

Technician Certifying Agency / Cert. Number*

Inspection Date