Chaparral Energy Valve Inspection Report

• Facility / Line Segment

• Conducted on

  Date

• Prepared by

• Location
  Address

Valve Information

• Size

  Select 2" 4" 6" 8" 10" Other

  • 2"
  • 4"
  • 6"
  • 8"
  • 10"
  • Other

• If "Other" please explain

• Type

  Select Relieve Valve Ball Valve Mainline Valve Other Relieve Valve/Ball Valve Grove Valve

  • Relieve Valve
  • Ball Valve
  • Mainline Valve
  • Other
  • Relieve Valve/Ball Valve
  • Grove Valve

• If "Other" please explain

• Valve Number

• Operating Condition

  Select 1. Valve Operates Freely 2. Valve Inoperative - Repair / Replace 3. Closed Valve - Did Not Operate

  • 1. Valve Operates Freely
  • 2. Valve Inoperative - Repair / Replace
  • 3. Closed Valve - Did Not Operate

• Valve Operator Condition

  Select 1. Operator Works 2. Operator Needs Repair

  • 1. Operator Works
  • 2. Operator Needs Repair

• External Leaks

  Select 1. No Leaks 2. Stern Seal Leak 3. Bonnet Leak 4. Flange Leak 5. Other

  • 1. No Leaks
  • 2. Stern Seal Leak
  • 3. Bonnet Leak
  • 4. Flange Leak
  • 5. Other

• If "Other" please explain

• Coating

  Select 1. Coating/Paint is Good 2. Needs Paint 3. Air-To-Ground Needs Repair

  • 1. Coating/Paint is Good
  • 2. Needs Paint
  • 3. Air-To-Ground Needs Repair

• Security

  Select 1. Valve Site Secured 2. Lock (s) Needs Secured 3. Fence /Gate Needs Repair 4. Barrier Needs Repair

  • 1. Valve Site Secured
  • 2. Lock (s) Needs Secured
  • 3. Fence /Gate Needs Repair
  • 4. Barrier Needs Repair

• Signs/Location Condition

  Select 1. Signs/Location Good 2. Sign Needs Replaced/Installed 3. Location Needs Work

  • 1. Signs/Location Good
  • 2. Sign Needs Replaced/Installed
  • 3. Location Needs Work

• Inspection Date

  Date

• Pictures

  Media

• Remarks/Comments

• Employee Conducting the Inspection

  Sign

• Supervisors Signature

  Sign

• Date

  Date