Form 17 (See Rule 75(8)(c)) REPORT OF EXAMINATION OF WATER-SEALED GAS HOLDER 1. Name of occupier and factory : 2. Situation and address of factory : 3. Name, description, distinguishing number or letter and type of gas holder. 4. Name and address of the manufacturer 5. (a) Number of lifts (b) Maximum capacity in cubic meters. (c) Pressure thrown by holder when full of gas 6. Particulars of gas to be stored in the holder 7. Particulars as to the condition of (A) Crown (B) Side shooting, including grips and cups (C) Guiding Mechanism (Roller carriages, rollers, pins, guide rails or ropes) (D) Tank and (E) Other structure, if any (columns, framing and bracing) 8). Particulars as to the position of the lifts at the time of examination 9). Particulars as to whether the tank and lifts were found sufficiently level for safe working and if not, as to the steps taken to remedy the defect 10). Date of examination and by whom it was carried out 11). Condition of Vessel a) External b) Internal 12). a) Are all fittings and appliances properly maintained and in good condition? b). Repairs if any, required and period within which they should be executed c). Any other condition which the person making the examination thinks it necessary for securing safe working 13). Other observations I certify that on (date) ...... the gasholder described above was thoroughly examined and such of the tests as were necessary made on the same day and that the above is a true report of any examination. Signature : Qualification Address Date (If employed by company or association , name and address of the association)
