Owner/Operator

Plant Contact

Job Site Address

City

State

Zip

Phone

Fax

Email

Contractor

Contractor Field Contact (Name)

Field Office Address

State

Zip

Phone

Fax

Email

Please check all that apply.

Chemical     Gas Processing     Refinery     Power     Pulp & Paper

Food     Drug     Cement     Municipal     DOT Pipeline

Other:

Description of Existing Condition:

Please check all that apply.

Not Leaking     Seam Leak     Crack     Pinhole Leak

Internal Corrosion     External Corrosion

Ambient Temperature at Time of Wrap (°F):

Material:

Type:    Schedule:    Grade:    Diameter:    Lin Ft:

Component:

Pipe     Tee     Nozzle     Elbow     Tank     Other:

Temperature:

Low (°F):    High (°F):    Constant (°F):    Cycling (°F):

Line Pressure:

Low (Psi):    Operating (Psi):    High (Psi)**:

**MAOP is the maximum allowable working pressure as defined in ASME B31G or API 579 or other calculation method.

Pipe Loading Pressure:

Operating: Design: Test: Comment:

Pipe Loading Axial:

Operating: Design: Test: Comment:

Pipe Loading Bending Moment:

Operating: Design: Test: Comment:

Safety Factor or Desired Operating Pressure of Wrap Design:

Safety Factor: to 1**

**MAOP is the maximum allowable working pressure as defined in ASME B31G or API 579 or other calculation method.

Desired Operating Pressure:

Line Chemistry:

Type of Chemical:      Concentration: %

Wall Thickness:

Current Wall Thickness:      Read Date:      Previous Wall Thickness:

Span:

Maximum Un-supported Span Length:      Lining Type:

Pipe Coating Type:

Details of Defect Area(s)

Defect 1

        Type of Defect: Mechanical      Corrosion      Erosion

        Length:      Width:      Depth:     

        Location:      Distance from Weld:

Defect 2

        Type of Defect: Mechanical      Corrosion      Erosion

        Length:      Width:      Depth:     

        Location:      Distance from Weld:

Defect 3

        Type of Defect: Mechanical      Corrosion      Erosion

        Length:      Width:      Depth:     

        Location:      Distance from Weld:

Defect 4

        Type of Defect: Mechanical      Corrosion      Erosion

        Length:      Width:      Depth:     

        Location:      Distance from Weld:

Defect 5

        Type of Defect: Mechanical      Corrosion      Erosion

        Length:      Width:      Depth:     

        Location:      Distance from Weld:

1. Plant Shutdown     Production Loss     Environmental

2. Emergency repair:  Yes    No

3. Wrap line while in service? Yes No

4. Line pressure can be lowered during maintenance to Psi.

5. Line temperature can be lowered during maintenance to F°.

6. Restrictions on surface preparation:
   

7. Describe elevation and length to perform maintenance:

Above Grade:      Below Grade:

Vertical Wrap est. ft.:      Horizontal Wrap est. ft.:

8. Conditions at time of repair:

Pipe Temperature (°F):      Ambient Temperature (°F):

9. Wrap Schedule:

Start Date:      End Date:

10. Time allowed to complete work and return line to service:

11. Services to be provided by the Owner/Operator:

12. What is the anticipated service life of the wrap?

Total Number of Months:

13. Design Calculation/Criteria:  Determines wrap specification for installation.
Yes    No