Loading...

This waiver serves as notification to our community members who wish for 20,000 Leagues Scuba and Aquatics to provide cylinder visual inspection services of requirements to disable the cylinder from future use should the cylinder fail inspection. Please read carefully, fill in all blanks and initial each paragraph before signing at bottom.

To:  20,000 Leagues Scuba and Aquatics and Visual Cylinder Inspectors:

I certify that I am the owner (or authorized representative) of high pressure cylinder(s), and have requested your visual inspection and/or hydrostatic inpsection test service. I understand that these vital safety examinations are needed at prescribed intervals to ensure the cylinder is safe for filling and continued service.  I have been informed that various damaging factors, such as those described in the book Inspecting Cylinders (5th Edition), by William L. (Bill) High and Mark A. Gresham, may cause my cylinder to fail either Visual Inspection or Hydrostatic assessment, as applicable.


I agree and authorize 20,000 Leagues Scuba and Aquatics, as a condition of having either service performed on my cylinder(s), to conspicuously disabled cylinders accepted for inspection if it does not meet standards published by PSI/PCI (Professional Scuba Inspectors/Professional Cylinder Inspectors).  I will receive a written report which identifies the reason for failure.  I understand that in this case, I will have the disabled cylinder and all components returned to me.


I agree that 20,000 Leagues Scuba and Aquatics has informed me that Nitrox cylinder markings will be removed if I choose not to Oxygen clean my Nitrox cylinders 


Cylinder serial numbers and services desired are specified at the end of this document. I certifiy that I will complete payment for these services whether or not inspections are completed with either a PASS or FAIL determination.


Due to insurance and safety matters for our staff and valued customers, if I do not agree with this policy, I understand that 20,000 Leagues Scuba and Aquatics is unable to accept the cylinders for servicing. 


 

First Cylinder Owner Name
First Name*
Last Name*
Phone*
First Cylinder Owner Date of Birth*
Date of Birth
First Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
First Cylinder Owner Signature*
Second Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Second Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Third Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Third Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Fourth Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Fourth Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Fifth Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Fifth Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Sixth Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Sixth Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Seventh Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Seventh Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Eighth Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Eighth Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Ninth Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Ninth Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Tenth Cylinder Owner Name
First Name*
Last Name*
Cylinder Owner Date of Birth*
Date of Birth
Tenth Cylinder Owner Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Cylinder Serial Number
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!