EMERGENCY KIT “B” INSPECTION FORM

Serial # _______________________ Next Inspection: _____________________________________________

Kit Location: ________________________________________________________________________________

It is recommended that all Emergency Kit owners establish and practice an inspection and training program on a regular
basis. Kits should be inspected to ensure that the equipment is complete and ready for emergency use. Kits include
contents lists, date stamped gaskets and box seals to assist inspection programs. Kit owners often coordinate routine kit
inspections with training exercises. This form is provided as a convenient record of inspections and equipment
expirations. Please contact Indian Springs Mfg. for further information.

Viton Gasket Recommended Shelf-Life Expiration - 4 yrs. (Date stamp is date of manufacture):

 #/KIT PART # DESCRIPTION NOTES

1 4A Hood
2 4-12BMV Gasket, Molded from Viton 
1 4C Yoke
3 4D Gasket, 1-1/4" OD x 11/16" ID x 1/16" thick
1 4E Stud
1 4F Cap Nut
5 4G Gasket, 15/16" dia. X 1/16" thick
5 4GG Gasket, 1" x 3" x 1/16" thick
1 9A Chain
1 9B Yoke
1 9C Cap Screw
1 9D Steel Patch
2 9EV Gasket, Molded from Viton 
1 12A Hood Assembly w/12V valve
1 12BBV Gasket, Molded from Viton 
1 12C Adjustable Bar Assembly
1 12MV Gasket, Molded from Viton 
1 101 Wrench, straight open end, 1-1/4" x 12" long
1 104 Wrench, 1-1/4" hex x 11” lg.
1 104B Wrench bar, 1" dia. x 20" long
1 106 Wrench, crowfoot special, 1-5/32" x 11" long
1 200B Wrench, 3/8" sq. box 1-1/4" open end x 7-1/4"
2 B-1 Drift Pin, 9/32" x 1/2" x 6"
2 B-2 Drift Pin, 7/8" x 1-1/4" x 8"
2 B-3 Drift Pin, 1-1/16" x 1-7/16" x 8"
5 B-4 Ring, vent valve packing, 7/8" OD x 15/32" ID x 1/4" thick
1 B-5 Paint Scraper
1 B-6 Hammer, Machinist, 3 lb.
15 B-7 Kit box seals
1 B-8 Gasket Sack
1 B-9 Valve yoke
1 B-10 Valve adapter
5 B-11 Gasket, 15/16" OD x 9/16" ID x 1/16" thick
1 B-12 Plastic box
1 151-B Kit box
1 153 Tool roll
2 IB Instruction booklet
1 CM Chlorine Manual
Viton is a registered Trademark of DuPont Dow Elastomers Ed. IFB Rev.-

Inspected by: ___________________________________ Date: _________________ Kit Seal: ____________

Indian Springs Mfg. P.O. Box 469, Baldwinsville NY 13027, phone (315) 635-6101, fax (315) 635-7473