LP Gas Check

*Time In:
 

Driver & Branch Information

*Branch Location:


*Driver:
 

Customer Information

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

Tank Information

*Out of Gas:

*Tank:

*Installation:

*Instructions:
 

Central Heating

*Manufacturer:





 If Other Manufacturer: 
*Fuel Type:


 If Other Fuel Type:
*Manual Shut-off:

*Sediment Trap:


 

Water Heater

*Manufacturer:





 If Other Manufacturer:
*Fuel Type:


 If Other Fuel Type:
*Manual Shut-off:

*Sediment Trap:


 

Range

*Manufacturer:





 If Other Manufacturer: 
*Fuel Type:


 If Other Fuel Type:
*Manual Shut-off:

*Sediment Trap:


 

Clothes Dryer

*Manufacturer:





 If Other Manufacturer: 
*Fuel Type:


 If Other 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:

 If Tank Condition is Poor/Bad:
*Paint Condition:

 If Paint Condition is Poor/Bad:
*Pigtail Condition:

 If Pigtail Condition is Poor/Bad:
*Fitting Condition:

 If Fitting Condition is Poor/Bad:
*Gauge Condition:

 If Gauge Condition is Poor/Bad:
*Relief Valve Condition:

 If Relief Valve Condition is Poor/Bad:
*Relief Valve Cap Condition:

 If Relief Valve Cap Condition is Poor/Bad:
*Fittings Leak Test:

 If Fittings Leak Test is Poor/Bad:
 

Note Regarding Piping/Regulator Operation:
For regulator type not used, please mark Other for Manufacturer and N/A in each additional box.
For additional regulators on the Two Stage, use the additional regulators comment section.

 

Piping/Regulator Operation & Condition: Twin Stage

*Twin Stage Manufacturer:



 If Other Manufacturer: 
*Model:
*Regulator MFR Date Code:
*Flow Pressure:
*Lock-Up Pressure:
 

Piping/Regulator Operation & Condition: Two Stage

*First Stage Manufacturer:



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



 If Other 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:
Security Code*

*denotes required fields