Gas Safety Checklist

Inspector*

RobertDavis

Please complete this checklist before the start of the installation event. If there are any unsafe installation, please do not hesitate to seek assistance from a licensed professional.

Business Name

Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Business Email Address

example@example.com

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Checklist

Rows	Yes	No	Remarks
Is the installation gastight compliant with AS/NZS5601.1 Gas installations standards?
Was the installation of the gas safe and secure?
Does the appliance have certification?
Is the room ventilated properly where the appliance will be installed?
Is it available for servicing and adjustment?
Are there any visible combustible types of equipment or elements?
Is there any obstruction?
Are there any signs of overheating appliances around the area where the gas will be installed?
Is the flame burner normal?
Does the appliance have any dust or debris?
Are the gas supply and burner pressure meter correct?
Is the heat exchanger in good condition?
Do the thermostats work?
Do the ignition devices work?
Is the gas cylinder in good condition, damaged, or rusty?
Is the gas cylinder positioned in a secure location?
Is the gas cylinder located in a well-ventilated position?
Does the staff know what to do if there's an emergency?
Is there an available fire extinguisher?
Does the supply pipes in good condition?
Does the supply hoses in good condition?

Any other criteria that is not in the list that you would like to include? If yes, please list them below:

Customer

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

By signing this form, I confirm that the gas is compliant and I make sure that this checklist is up to date. I also confirm that all information I entered in this form is accurate and true to the best of my knowledge.

Date Signed

Date

Gasfitter Signature