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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.

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*
First Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
First Cylinder Owner Signature*
Second Cylinder Owner Name

First Name*

Last Name*
Second Cylinder Owner Date of Birth*
Second Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Third Cylinder Owner Name

First Name*

Last Name*
Third Cylinder Owner Date of Birth*
Third Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Fourth Cylinder Owner Name

First Name*

Last Name*
Fourth Cylinder Owner Date of Birth*
Fourth Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Fifth Cylinder Owner Name

First Name*

Last Name*
Fifth Cylinder Owner Date of Birth*
Fifth Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Sixth Cylinder Owner Name

First Name*

Last Name*
Sixth Cylinder Owner Date of Birth*
Sixth Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Seventh Cylinder Owner Name

First Name*

Last Name*
Seventh Cylinder Owner Date of Birth*
Seventh Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Eighth Cylinder Owner Name

First Name*

Last Name*
Eighth Cylinder Owner Date of Birth*
Eighth Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Ninth Cylinder Owner Name

First Name*

Last Name*
Ninth Cylinder Owner Date of Birth*
Ninth Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Tenth Cylinder Owner Name

First Name*

Last Name*
Tenth Cylinder Owner Date of Birth*
Tenth Cylinder Owner Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
Parent or Guardian's Email Address

Email*

Confirm Email*
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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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Cylinder Serial Number

Cylinder Number

Cylinder Number
Click to customize pull down
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.


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