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5 GASChe(k• <br />weg-&V Iv ead yax gngarc psrem <br />Account Number <br />Name I I C 1.) e 5 c e �- s <br />rc <br />Address -' >> 2i <br />City, State. Zip i' •''-= <br />Telephone. Office Home <br />Residential Gas Appliance System Check <br />Company/Location =' Y 7`' /, G <br />Call Date <br />Date GAS Check• Requested 1 - 7 -G• <br />Call-Taker's Name ✓CJ�i/J ry-s'4 _- <br />Instructions /' - ' j i' S r ^ /r - <br />PERFORMANCE CHECK: ITEM <br />Centrai I ),^",sting 1 <br />Room Heater 2 <br />Water Heater 3 <br />Range 4 <br />Clothes Dryer 5 <br />6 <br />Manufadurer <br />7 <br />Model No <br />— <br />Senal No <br />L• `i (' iJU %� : '7 <br />G <br />Fuel <br />BTU Rating <br />Manual Shulofl (Irstalled'Emsting) <br />Y` <br />Sediment Trap (Installed/Existing) <br />Control Mfr Nhodel No <br />Rlol(s)IRlol Safety System <br />-'%IA <br />Ignibon System(s) MIr./Model No <br />Thempstals I[Model No. <br />Bumer(syCombusten Chamber <br />tenting SystemlDraft Diverter') <br />Combustion Air <br />Red Tag (removed <br />from service)lRecall <br />TANKICYLINDER (Additional Serial Numbers) <br />SIZE <br />SERIAL NUMBER <br />MFR. <br />MFR. DATE <br />LAST <br />TEST DATE <br />LOCATION <br />CONDITION CF: <br />RELIEF VALVE <br />FITTINGS <br />LEAK TEST <br />TANK <br />PAINT <br />I PIGTAIL <br />FITTINGS <br />GAUGE <br />COND I <br />DATE <br />I CAP <br />i1C_l <br />PIPINGIREGUTATOR OPERATIOWCONDITION <br />SINGLE <br />PIPING <br />REGULATOR MFR <br />DATE (CODE) <br />M'R. <br />REGULATOR <br />CONDITION <br />MODEL <br />REG. VENT <br />POSITION <br />HOW <br />PROTECTED <br />FLOW <br />PRESSURE <br />LOCK -UP <br />PRESSURE <br />MATERIAL <br />SIZE <br />STAGE <br />IN INC <br />IN WC <br />TV70 <br />1st <br />PSIG <br />PSIG <br />STAGE <br />2M <br />N WC <br />IN YiC <br />SYSTEM LEAK TEST <br />Comments <br />SINGLE STAGE/START <br />INTEGRAL/ <br />SECOND STATE <br />PRESSURE <br />END PRESSURE <br />TIME HELD <br />SYSTEM OK <br />(INCHES WC) <br />pNCHEswc) <br />_ .� <br />TWO <br />STAGE <br />1st <br />I 2nd...- <br />This inspedm covers (propanelLP-gas) items and equipment visible and accessible to Lhe service <br />technician and represents the conditions existing on the date of inspection. II does not cover talent or <br />manufacturing defects, the internal working of sealed equipment or structural components, and cannot be <br />con�(t/�/ed, b mve�Wre q unf happenings, <br />I L� ETA (Please print name) <br />• Krm how to lure oft the gas in case of emergency. <br />• Have smelled propane and can detect its odor. <br />• Have received the consumer safety infogwlion and material. <br />• Had gas system deficiencies and/or ions, O any, dearly explained to me. <br />•!gym sa656eQ WIh the wrvim weM firmed. <br />v (Customer's Signature) <br />Reference Invoice No. Date <br />I, �J�i•'/J �> ETG (please print name) <br />certify that I ham completed the Boom Check as prescribed. <br />Pudormed Odor Test c1 yes <br />- <br />Performed Leak/Pressure Test IJ ,nos <br />Placed Safety Decal Cl Yes <br />Left ConsumerSafaly I rmatilaf " giial C3 Ygs-' <br />(Service Technii 'sSignature)ldr? <br />0 NPGA 1998 N5610 <br />CUSTOMER COPY <br />