LP Gas Check Form

*Time In:

Driver & Branch Information

*Branch Location:
*Driver:

Customer Information

*Account Number:
*Customer Name

Tank Information

*Out of Gas:
*Tank:
*Installation:
*Instructions:

Central Heating

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

Water Heater

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

Range

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

Clothes Dryer

*Manufacturer:
*Fuel Type:
*Manual Shut-off:
*Sedimen

Tank/Cylinder Information & Condition

*Tank Size:
*Tank Manufacturer:
*Tank Serial Number:
*Distance from Building:
*Tank Condition:
*Paint Condition:
*Pigtail Condition:
*Fitting Condition:
*Gauage 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:
*Model:
*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:
*Seceond Stage Model:
*Second Stage Regulator MFR Date Code:
*Second Stage Flow Pressure:
*Second Stage Lock-Up Pressure:
*Additional Regulators:

Pressure Test (New System)

*Start Pressure:
*End Pressure
*Time Held

System Leak Test

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

 

 

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

If you would like to receive an emailed copy of this LP Gas Check Report,
please enter your email address below.

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: NPGA 0070, NPGA 0008, 4062-99, 3101

*Electronic Driver's Signature:

 

*Time Out:

*denotes required fields