[Prescribed under Rule 56-Al


1. Name of occupier of factory 

2. Situation and address of factory

3. Name, description, distinguishing number or letter and type of gas-

4. Name and address of the manufacturer

5. (a) No. of lifts
    (b) Maximum capacity in cubic metres (cub.ft.)
    (c) Pressure thrown by holder when full of gas.

6. Particulars of gas to be stored in the holder.

7. Particulars as to the conditions of-
   (a) Crown.
   (b) Side sheeting, including grips and cups.
   (c) Guiding mechanism (Roller carriages, rollers, pins, guide rails or
   (d) Tank
   (e) Other structure, if any (columns, framing and bracing).

8. Particulars as to the position of the lifts at the time of examination.

9. Particulars as to whether the tank and lifts were found sufficiently levelled for safe working and if not, as to the steps taken to remedy the defect.

10. Date of examination and by whom it was carried out.

11. Condition of vessel
     (1) external
     (2) internal

12. Are all fittings, appliances properly maintained and in a good condition,
repairs if any required and period within which they should be executed
and any other condition which the person making the examination thinks
fit necessary for safe working.

13. Other observations.

I certify that on ............................. the gas-holder described as above was thoroughly examined and such of the tests as were necessary made on the same day and that the above is a true report of my examination.

Signature :

If employed by a Company or Association, give name and address. A copy of the report in Form "X" shall be kept in the register and both the register and the report shall be readily available for inspection.