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Account Number American Dist�ibuting Company <br /> Name :; ' 1361845thAvenueNE, Marysville, WA98271 <br /> Address � • 360-6583751 or 7•800-579-6777 <br /> City, State, Zip " ` <br /> Phone # Propane Gas System Check <br /> rn��a�� �3 <br /> Appliance Manufacturer Model No. Serial No. Red Tag <br /> Furnace <br /> Fireplace <br /> Water Heater <br /> Cook Stove <br /> Clothes Dryer <br /> TanklCylinder <br /> Size Serfal No. Manufacturer Year Manufactured Fittings Leak Test <br /> , <br /> � � 1 � <br /> — � <br /> System Leak Test <br /> Start Pressure(psi) End Pressure (psi) Time Held System OK <br /> Syslem Block Test '' ' <br /> Two Stage/ 1sl <br /> Twp Stage 2nd <br /> UG Piping <br /> Inside Piping <br /> Piping MaUSize Tank Swap oul <br /> Piping Material Piping Size ; � ,i - ', �-�' ` � ' `' ' - � � ' �' <br /> Twin Slage ?, , --;t �V'\1 l.�V <br /> Two Slagel 1st � ! -,: i ln�(�f ti, <br /> Two Stage/2nd <br /> This inspec�ion covers (propanclLP-c�as) i�ems and e�uipment Comments: � � '� ' ' ` ��' ' �r� � <br /> aaessible to �he service technician anA represenls the condi�ions �- _ . . , , , -- . + �-� � � � . � <br /> exislin� on Ihe daie ol inspection. It does nol cover latent or <br /> inanufacWnng defeds, �he internal working of sealeA equipmen�, or � � <br /> sVuc�ural componenl5. and cannol be conslrued b cover lu�ure or <br /> unforeseen happenings. <br /> i, . . .. _(Pdm namc� I. � '� ' .. (print name) <br /> . Know haw to Wm off gas in case of an emer�ency CeAi(y that I have completed the System Check as prescribed. <br /> . Have received consumer safety inlormation and matenal <br /> . Had any gas system defciencies andlor covections, Pefformed Odor TeSI <br /> if any.erp�ained fo me. pe�iormed Leak/Pressure Test - <br /> • Am satisfied wilh Ihe service work pertormed. De�e�___ <br /> Cuslomer SignaWre Service Technician Signature <br /> Please contact us if you add/change gas appliances or modify youi gas system �_q <br />