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MONTHLY SCBA/SABA INSPECTION FORM <br /> SCBA/SABA No.: Cylinder No.: <br /> Mask No.: Apparatus: <br /> Date: Inspector's name: <br /> I. Visual Inspection <br /> Mask: <br /> For facepiece-mounted regulators: Low-pressure hose: <br /> Intermediate pressure hose in good condition. Exhalation valve. <br /> Gaskets. 0-rings, gaskets, and screens. <br /> Lens, hardware, buckles, straps clean and in good Speaking diaphragm. <br /> condition. <br /> Connections and threads. Lens, hardware, buckles, etc. <br /> Cylinder: Regulator: <br /> Cylinder pressure—minimum 90%of rated storage. Regulator gauge reads the same as tank gauge. <br /> Check for gouges,corrosion, chipping, and Exhalation valve on facepiece-mounted <br /> cracking. regulators. <br /> Gauges and valves_ Gaskets, 0-rings, screens. <br /> Seals, gaskets, and screens. Alarm. <br /> High-pressure hose is in good condition. High-pressure hose in good condition. <br /> Hydrostatic test date: Steel and aluminum—5 years:Composite—3 years, 15 year life <br /> Backpack <br /> Straps, buckles, cylinder, and frame in good Shoulder and waist straps in good condition and fully <br /> condition, extended. <br /> II. Operational Inspection <br /> Don mask, check facepiece seal. Operate pressure/demand switch and check for <br /> positive pressure. <br /> Verify exhalation valve operation. Operate bypass valve. <br /> Open cylinder valve and pressurize system. Tank SCBA valves back to operational position. Verify low <br /> valve operates smoothly. pressure alarm activates while closing cylinder valve. <br /> Check for leaks in hose,alarm or regulator. Clean, recharge, and restore to service. Remove <br /> and report any unit that fails to operate properly. <br /> Signature of Inspector: <br /> Page 9 of 9 <br />