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GAS APPLIANCE SYSTEM CHECK I ._ _ _
<br /> __.- __ __ _ . _- ___ -— ' Nome Heating �
<br /> '_ Range ,__ ; _ _ - ,
<br /> performance Check._Item ; ____ __ - �
<br /> Water Heater Y _
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<br /> 'Maitufacturer _ _ _ _ _ __ ___ _
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<br /> �Model # _ --_. . _ _ ,
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<br /> SeXiai �` _ _ __ __ _ , . _ _
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<br /> - - - . �,�,�, OC�
<br /> __ _ _ fV/r`�. Jt: _ . _
<br /> 'gTn.J _ _ , _ _ .
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<br /> �9�' _ _ _ _ . __. _ _ _ _ — _ __:
<br /> �'�,Mc`3i"iL1G't� `~J'�1Ut0� i i:�nc a F� .ti i,:; . _._ _. ._ . _. .. _ .._ .... _._ _ _!... ...._. . ..._. � -__ __._. ._ ,� �''�..
<br /> _—_-__. _... _ -._ ,' ___. .......�
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<br /> �E:C�i(11�11� i i`S� :__ __ _, _ _
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<br /> I C,oflfi'G+� Mft��MC1dE'.�#t _ --_ i ___ _ _ . _ _ i
<br /> F�liot�s) _ _ - -_ _ __ _ _ ,
<br /> i Ignit?�s,� System(s} Mfc� _ _ . _ _ _ _ _ ,
<br /> Tk�errnc�st�t(s} Ntfa _ _ > _ , __
<br /> Pil�t Safety :�ysterr? _ _ _. __ '
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<br /> �3urr,�rtsi _ _ h�,p,
<br /> Nit� _ _ +_
<br /> C::arnb��stian Chamber _ __ _ _
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<br /> _ _ N!A NiA _ __ - _
<br /> �Fifters . _ _ _ ___ _ _ _ _ ;
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<br /> -- f`�;�� IV;P ._ _ __
<br /> Motor/Rfower�+�Eamp _ _ _ _ Nrt`, :
<br /> - _ ��N P1;f�, _ __ _
<br /> ,Suffic�ent Rett�rr�/�er , _ _ __ _ _
<br /> I,l�r�ft D`�E=.rtcy� _ ! _ . _
<br /> Ver,tir�rs _ _ _ '
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<br /> '�;os�i���.astio�i E=yir . ! _. _ _ . _ _. _.. . -_
<br /> {�21� �ciC� i.�rn ,t.r �n ,� e.�; + __ _ _ _ ___ r
<br /> Aut« Fr31 Sch�clu4e _ _ ; __ ' _ _ _ . _
<br /> _ _
<br /> � __ _ . ___ _ iyon � Candit�on I�Ccnd�U�n lief Valve � ��ttings I
<br /> Tank � � li�der __��o�d -- ___ ,__ i --�-
<br /> _ _ M�r &DatF 1 ate Test T�3nk C,nnclitic>r Fittin s � Gauge I.el �ate _'_ Ca Le�k Test
<br /> � i_or,atu�r +
<br /> S�r'ea� - Da�e -
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<br /> fecks. the intern�?wcrking of seaied eqi:ipment. cr siructurai components. and cannot
<br /> �fhis mspeetion covers (propanelL�-g�s) items a��d equipment visible ana aceessit�le tn th� �ervice tecY�nVcian and represents the conditior�s exisiing or�
<br /> the date of inspection. It does not cover iatent or manufacturing de
<br /> be constriiecf tc�;�ver f��ture def�cts or unf�reseen happeni�7q"�
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<br /> _ , ,p�A�se Print}
<br /> - (Please Printl
<br /> Certify that I trave cc�rnpleted the Systerr'i C,heck as prescnbed.
<br /> . Knu��huw to turn cff g�s fn case of emergency
<br /> Perfarmzd Qdor Test �I Yes F'erformed Pressure Test U Yes
<br /> • Have smelleci propane and can delect fts odor piaced Safety Decal '.�Yes Leffi Ct�nsumer Safety Info �Yes
<br /> � Have raceived the Consumer Safety informatior,.
<br /> - Had gas system deficiencies and i or corrections,if any.cleariy expiained to m�..
<br /> •Am satisfied �tth th.e service work per�orrn�d . .
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<br /> --- -- - Serv�ce Techrncian Signattire
<br /> Customer Signature�
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