LP Gas Check Form

*Time In:

Driver & Branch Information

*Branch Location:

Customer Information

*Account Number:
*Customer Name:
*Customer Address:

Tank Information

*Out of Gas:

Central Heating

*Fuel Type:
*Manual Shut-off:
Sediment Trap:

Water Heater

*Fuel Type:
*Manual Shut-off:
*Sediment Trap:


*Fuel Type:
*Manual Shut-off:
*Sediment Trap:

Clothes Dryer

*Fuel Type:
*Manual Shut-off:
*Sediment Trap:

Additonal Appliances


Tank/Cylinder Information & Condition

*Tank Size:
*Tank Manufacturer:
*Tank Serial Number:
*Distance from Building:
*Tank Condition:
*Paint Condition:
*Pigtail Condition:
*Fitting Condition:
*Gauge Condition:
*Relief Valve Condition:
*Relief Valve Cap Condition:
*Fittings Leak Test:

Note Regarding Piping/Regulator Operation: For regulator type not used, please mark N/A. For additional regulators on the Two Stage, use the additional regulators comment section.

Piping/Regulator Operation & Condition: Twin Stage

*Twin Stage Manufacturer:
*Regulator MFR Date Code:
*Flow Pressure:
*Lock-Up Pressure:

Piping/Regulator Operation & Condition: Two Stage

*First Stage Manufacturer:
*First Stage Model:
*First Stage Regulator MFR Date Code:
*First Stage Flow Pressure:
*First Stage Lock-Up Pressure:
*Second Stage Manufacturer:
*Second Stage Model:
*Second Stage Regulator MFR Date Code:
*Second Stage Flow Pressure:
*Second Stage Lock-Up Pressure:
*Additional Regulators:

Pressure Test

Required any time a new system is installed or new piping is installed.

*Start Pressure:
*End Pressure
*Time Held

System Leak Test

*Start Pressure:
*End Pressure:
*Time Held:

Additional Comments:


Service Work Done & Materials Used

*Ft. Tubing:

*Ft. Trenching:

*Fittings & Materials Used:

*Description of Work Completed:


Disclaimer: This inspection covers LP gas distribution system equipment visible and readily accessible to the service technician and represents the conditions existing on the date of inspection. It does not cover latent or manufacturing defects, the internal workings of sealed equipment or structural components, and cannot be construed to cover future or unforeseen happenings existing on the date of inspection.


*Customer Acknowledgement: I acknowledge, by checking each of the following items, that:

*Electronic Customer Signature

To receive an emailed copy of this agreement, please enter your email address below.
If no email address is provided, a paper copy will be mailed to the address entered above.

Customer Email Address:


*Driver/Service Technician Acknowledgement: I, certify that I have completed the following system safety checks as prescribed:

Consumer Safety Info Packet Contains the Following: PRC003121, CSB 05 3126117

*Electronic Driver's Signature:


*Time Out:

*denotes required fields

Security Code*