Test and Tag Report - Little John and Co

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Class 1 Appliance

• Plant Name. --- Plant Number. --- Tag Number

• Pass or Fail or more action required?

  Pass

  Fail

  Requires More Attention,

  See Image Below

Class 2 Appliance

• Plant Name. --- Plant Number. --- Tag Number

• Pass or Fail or more action required?

  Pass

  Fail

  Requires More Attention,

  See Image Below

Extension Leads

• Plant Name. --- Plant Number. --- Tag Number

• Pass or Fail or more action required?

  Pass

  Fail

  Requires More Attention,

  See Image Below

Multi Boxes

• Plant Name. --- Plant Number. --- Tag Number

• Pass or Fail or more action required?

  Pass

  Fail

  Requires More Attention,

  See Image Below

Fail Items

• Plant Name. --- Item Number

• Add media

  Media

Next Test of Equipment Scheduled Date.

• Next Test Due Date

  Date

Testers Sign Off

• Signed by the Owner of Listed Equipment

  Sign

• Signed by the Tester of Listed Equipment

  Sign