Administrative Forms

PBT Instrument Calibration and Maintenance Log (TD-053)

TD-053 - Preliminary Breath Test Instrument Calibration and Maintenance Log

When a PBT is inspected, calibrated, or repaired, the TD-053 is used to document these actions.

• Record all results obtained, regardless of whether they are within, or out of tolerance.

Completion and Retention:

• Each PBT instrument shall have a separate log.
• Begin a new log sheet each calendar year and retain the log for the current year plus three years.
• Make an entry on the log sheet for each inspection and calibration.

Instructions for completion of the TD-053:

1. ORI number of Department/Agency that owns the PBT instrument.
2. Calendar Year - enter the current year.
3. Department/Agency that owns the PBT instrument - printed department name.
4. Instrument Serial Number - number located on the back of the PBT FC10.
5. Instrument Model - enter model number (FC10).
6. Date - month and day (i.e.: 5/20).
7. Signature of operator - operator performing the maintenance, repair, or calibration.
8. Operator's Department – print name of operator’s department.
9. Operator ID Number- operator's certification number.
10. Verification Results - results of the dry check (i.e., 0.078).
11. Calibration/Maintenance Performed - print what operation was performed (“Verified” or "Calibrated").
12. Dry Gas Lot Number - Enter the lot number appearing on the dry gas canister.