Inspection of Relief Device

‫چک لیست بازرسی شیر فشار شکن‬ Check List

Relief Device Data

☐ Rupture Disk ☐ Safety Relief Valve

Device Type
☐ Other? Explain: …………………………………………………………………………

Manufacturer

Part Number

Serial Number

Rated Flow Capacity

Converted Flow Capacity

Set Pressure

☐ CE/ PED ☐ ASME

Certification Type
☐ Other? Explain: ………………………………………………………………….……

Test/ Inspection Data

☐ No ☐ Yes Is the inspected device in

conformance with the
☐ Other? Explain: …………………………………………………………….………… purchase order:

☐ No ☐ Yes
Are the manufacturer’s
markings legible?
☐ Other? Explain: ……………………………………………………….………………

☐ No ☐ Yes
Tamper resistant devices
are intact?
☐ Other? Explain: ………………………………………………….……………………

☐ No ☐ Yes Are there any flow

restrictions present? (Like:
☐ Other? Explain: …………………………………………….………………………… gags, blinds, closed valves,
bent piping, …)

☐ No ☐ Yes Is there any unacceptable

leaks including those to
☐ Other? Explain: ……………………………………………….……………………… relief path?

☐ No ☐ Yes Discharge and relief

piping are directed
☐ Other? Explain: ……………………………………………….……………………… toward a safe location?

Date Revision Issue Form

MIC-CL-2110-01
1401.06.29 0 0
 Inspection of Relief Device
‫چک لیست بازرسی شیر فشار شکن‬ Check List

☐ No ☐ Yes Is it equipped with

upstream and
downstream block
☐ Other? Explain: ……………………………………………………….………………
valves?
If the answer to the
☐ No ☐ Yes previous question is yes,
then: Are locking handles
☐ Other? Explain: ……………………………………………………………….……… of the black valves
secured in open position?
☐ No ☐ Yes Related piping is property
☐ Other? Explain: ……………………………………………………………….……… supported?
Related piping is in good
☐ No ☐ Yes condition? (Please consider
the reaction force of discharge,
☐ Other? Explain: ……………………………………………………………….……… Look for any sign of fatigue,
crack, etc. – Visual inspection )

☐ No ☐ Yes
Are the valve body drains
open?
☐ Other? Explain: …………………………………………….…………………………

☐ No ☐ Yes Is it equipped with a

☐ Other? Explain: ………………………….…………………………………………… proper lift lever?
☐ N.A. ☐ No ☐ Yes Is the lift lever positioned
☐ Other? Explain: ………………………….…………………………………………… and functioning property?
Is a functioning gauge is
☐ No ☐ Yes
installed between relief
valve and rupture disk
☐ Other? Explain: ………………………….…………………………………………… combinations?

☐ No ☐ Yes Is the Non-reclosing

relief is property
☐ Other? Explain: ………………………….…………………………………………… oriented? (check flow on
rupture disks)

Tests

☐ No ☐ Yes
On-stream test required?
☐ Other? Explain: ………………………….……………………………………………
☐ NA ☐ No ☐ Yes Approved on-stream test
☐ Other? Explain: ………………………….…………………………………………… procedure available?
☐ NA ☐ No ☐ Yes On-stream test passed?

Issue Revision Date

0 0 1401.06.22
 Inspection of Relief Device
‫چک لیست بازرسی شیر فشار شکن‬ Check List

(within 5% or 3 psi of rated

☐ Other? Explain: ………………………….…………………………………………… pressure)

☐ No ☐ Yes
Shop test required?
☐ Other/ Explain: …………………………….……………………………………………
☐ NA ☐ No ☐ Yes Approved shop test
☐ Other/ Explain: …………………………….…………………………………………… procedure available?
☐ No ☐ Yes Shop Test passed?
Within 5% or 3 psi of
☐ Other/ Explain: …………………………….…………………………………………… related pressure.
All the above-mentioned
☐ No ☐ Yes inspection results were
satisfactory and packing
☐ Other/ Explain: …………………………….…………………………………………… of the device could be
done?
Packing of the
☐ No ☐ Yes
device/devices were in
accordance with the
☐ Other/ Explain: …………………………….…………………………………………… approved packing
procedure?

Issue Revision Date

0 0 1401.06.22