LABORATORY

LETTERHEAD School District: ___________________________________________________

HERE DSA FILE # _____________
Attn: ___________________________________________________
DSA APPL. # _____________
Address: ___________________________________________________
___________________________________________________ DSA / LEA # ______________
Weld I.D.: __________________________________
ULTRASONIC (NDT) TEST REPORT Material Thickness: ___________________________
Weld Joint AWS: _____________________________
Project Name: ____________________________________________ Welding Process _____________________________
Report Date:______________________________________________ Quality Requirements – Section No. ______________
Location in Structure: ______________________________________

Decibles Discontinuity

Angular Distance
Attenuation

Indication
Reference
Indication

Discontinuity
Line Number

(sound path)

"A" Surface
Rating
Factor
Transducer

Depth from
+
From Face

Evaluation
Indication

Level

Level
X X
Number

Length
Angle

Distance
Y
Leg1

a b c d From X From Y Remarks

10

11

12
General Note: This form is applicable to Section 2, Parts B or C (Statically and Cyclically Loaded Nontubular Structures) of ASW D1.1. Do NOT use this form for Tubular structures (Section 2, Part D).
I, the undersigned, certify that the statements in this record are correct and that the welds were prepared and tested in conformance with the requirements of Section 6,
Part F of AWS D1.1/D1.1M, (_______) Structural Welding Code – Steel
(year)

REMARKS: ________________________________________________________________________________________________
cc: Project Architect The Material □ WAS □ WAS NOT
SAMPLED AND TESTED IN ACCORDANCE
Structural Engineer WITH THE REQUIREMENTS OF THE Signature Date
DSA APPROVED DOCUMENTS.
Project Inspector
Print Name / Title
The Material Tested
DSA Regional Office
□ MET □ DID NOT MEET
DSA-210 Template (02/06) THE REQUIREMENTS OF THE CERTIFICATION #
DSA APPROVED DOCUMENTS.