Project Information
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Document No:
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Project number AUL-
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Network design approval No:
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Address:
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Date:
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Prepared by:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
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Person controlling the risks on site:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
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Add signature
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Names of personnel on site affected by the works:
- N SMART
- M DUCE
- K AINSWORTH
- A AINSWORTH
- R HITCHIN
- A MANSELL
- D SMART
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Network operator:
- NG
- SGN
- WWU
- NGN
- ESP
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Team leader to take pictures of the site prior to works:
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Add pictures:
Pre works pictures
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Pictures of site before works carried out.
Site works
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Are persons affected by the works:
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If so who:
- Operitives
- Sub-Contractors
- Other persons / public
- Site visitors
Work activities
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Are works to be carried out:
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Works to be carried out:
- New Connection
- Disconnection
- Alteration
- Upgrade
Site activities will involve the following
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Are there risks associated with this project ?, if the answer is yes you must assess the initial level of risk, if you see the risk as HIGH you must not proceed an contact a senior manager. If you assess the risk as medium you can proceed and carry out a risk assessment.
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INITIAL RISK LEVEL:
- HIGH - DO NOT CONTINUE / SEEK ADVICE
- MEDIUM
- LOW
Pre start checks
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Has the team leader ensured that the following has been filled in / on site:
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Team leader to ensure the following
- Risk assessment carried out
- Correct site address
- All plans on site
- F91 up to date
- BA checked
- Fire ex checked
- All fittings on site
- No scaffolding present
- All plant & tools on site
Team signatures
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All team members to comply with the instructions issued by the team leader and abide by company risk assessments, method statements. All team members to print & sign below
Team member to sign below:
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Add signature
Site specific risk assessment
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Risk assessment:
Risk assessment
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Initial risk
- HIGH - DO NOT CONTINUE / SEEK ADVICE
- MEDIUM
- LOW
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Who affected
- Operitives
- Sub-Contractors
- Other persons / public
- Site visitors
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Potential hazard and associated risk
- Traffic
- Site plant
- Underground services
- Above ground services
- Excavations
- Inclement weather
- Gas escape
- Scaffolding
- Pneumatic pressure testing
- Purgeing
- Slips, trips, falls
- Grundomat mole
- Fire
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Control measure
- RA 1 General safety
- RA 2 Chapter 8
- RA 3 Working near underground plant
- RA 4 Excavations & backfilling
- RA 5 Materials handling
- RA 6 Installation of mains > 7bar
- RA 7 Installation of services > 7 bar
- RA 8 Guided moling
- RA 9 Profuse electrofusion
- RA 10 Profuse butt fusion
- RA 11 Connections
- RA 12 Test & commission > 7 bar
- RA 13 Steel main laying
- RA 14 Steel welding
- RA 15 Corrosion protection
- RA 16 Defective materials
- RA 17 installation of gas equipment
- RA 18 Hand over documentation
- RA 19 Gas escapes
- RA 20 Environmental assessment
- RA 21 Waste management
- RA 22 Flow stopping operations
- RA 23 Use of coil trailers
- RA 24
- RA 25
- RA 26
- RA 27
- RA 28
- RA 29
- RA 30
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Revised risk
- HIGH - DO NOT CONTINUE / SEEK ADVICE
- MEDIUM
- LOW
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Person responsible for control measures / monitoring
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
Additional information
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Please use this section to add any additional information including pictures if necessary.
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Add media
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Additional information added by
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- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
RO / NRO
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RO / NRO
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Does this connection require an RO or NRO, if yes a CP will be attending site to supervise the connection. A copy of the RO or NRO will be in the team site pack sent via the Adobe pdf file.
- N/A
- YES - RO
- YES - NRO
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RO - NRO Information:
RO - NRO Information
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Clearance to proceed:
Fittings used
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Team to scan barcode of each fitting, if a barcode is not available please take a picture:
Scanned fitting:
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Tap to read barcode:
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Picture of fitting if no barcode available.
Picture
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Tap to take picture:
As laid mains / service
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Complete the as laid for the service installed to include 2 x measurements at right angles for each connection point, change in direction, valve and meter box / kiosk
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Picture of as laid:
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Complete the as laid for the main installed to include 2 x measurements at right angles for each connection point, change in direction, valve and meter box / kiosk
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Picture of as laid:
Valve card
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Service Valve:
Service valve details
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Valve number:
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Designation:
- Fire valve
- Line valve
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Network number:
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Function:
- Critical M1
- PRI M2
- Maintained M3
- Accessible M4
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Location details:
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District information:
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Pressure tier:
- LOW
- MEDIUM
- INTERMEDIATE
- HIGH PRESSURE
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Address of additional property affected if valve is operated:
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Address of additional property affected if valve is operated:
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Address of additional property affected if valve is operated:
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Address of additional property affected if valve is operated:
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Size / Nominal bore:
- 32mm / 1"
- 63mm / 2"
- 80mm / 3"
- 100mm / 4"
- 150mm / 6"
- 200mm / 8"
- 250mm / 10"
- 300mm / 12"
- 400mm / 18"
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Make / type:
- AVK DONKIN
- AVK CERTUS
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Serial number:
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Batch number:
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Protective wrapping:
- YES
- NO
- N/A
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Body vent on valve:
- YES
- NO
- N/A
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Flange class:
- PN 16
- N/A
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Date installed:
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Specification:
- GIS / V4
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Scan valve barcode:
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Address of additional property affected if valve is operated:
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Mains valve:
Main / Line valve details
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Depth of cover (mm):
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Test pressure (mb):
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Test type:
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Organisation:
- NG
- SGN
- WWU
- NGN
- ESP
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Status:
- OPEN
- CLOSED
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Additional information:
- VALVE IS 1/4 TURN
- VALVE HAS CHAMBERS AND COVERS
- Valve is isolation valve to the addresses below and if / when operated would effect the addresses below
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Installed by:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
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Test date & time:
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Location drawing of valves:
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Bypass fitted:
- YES
- NO
- N/A
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Bypass point size:
- 32mm / 1"
- 63mm / 2"
- 80mm / 3"
- 100mm / 4"
- 150mm / 6"
- 200mm / 8"
- 250mm / 10"
- 300mm / 12"
- 400mm / 18"
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Spindle size:
- Yes
- No
- N/A
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Spindle depth:
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No of turns to close:
-
Maximum operating pressure:
- LOW
- MEDIUM
- INTERMEDIATE
- HIGH PRESSURE
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Pressure points fitted:
- YES
- NO
- N/A
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Concrete hunching fitted:
- YES
- NO
- N/A
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Valve cover fitted:
- YES
- NO
- N/A
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Marker post installed:
- YES
- NO
- N/A
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Above or below ground:
- ABOVE
- BELOW
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Spindle depth:
-
Direction to close:
- Clockwise
- Anti-clockwise
Test cert (services)
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UNDER NO CIRCUMSTANCES ARE THERE ANY PERSONNEL TO BE IN AN EXCAVATION DURING THE PRESSURISATION, TEST, OR DEPRESSURISATION OF THE PIPES BEING TESTED. <br><br>PLEASE ACKNOWLEDGE YOU WILL COMPLY WITH THIS INSTRUCTION.
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Service test certificate:
Service test certificate
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Network:
- NG
- SGN
- WWU
- NGN
- ESP
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Plot, house, Flat, Unit number / name or take a picture of the MPRN label below:
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Picture of MPRN liable:
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Meter box type:
- Meter room
- Bolt on meter box
- Inset meter box
- Semi concealed meter box
- Multi box meter box
- Client built meter enclosure
- GC2 FS - U16
- GC2 WM - U16
- GC2 WM MP - U16
- GC2 MULTI - WM / FS
- GC3 WM - U25
- GC4 - U25 / U40
- GC4 PLUS MP
- GC5 - U65 LP / MP
- GC6 LP - U65 / U100
- GC6 - EXPL - U65 / U100
- GC6 MP - U65 / U100
- GC7 LP - U65 / U100
- GC7 - EXPL - U65 / U100
- GC7 MP - U65 / U100
- GC7 + LP U65 / U100
- GC7 + EXPL - U65 / U100
- GC7 + MP - U65 / U100
- GC8 MP
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Has correct ventilation been installed:
- YES
- NO
- N/A
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Installer:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
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Plot No / House No
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Works carried out:
- New Connection
- Disconnection
- Alteration
- Upgrade
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Test gauge type:
- Druck 705is
- 48" water gauge
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Serial number:
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Pressure tier:
- LOW
- MEDIUM
- INTERMEDIATE
- HIGH PRESSURE
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Test pressure:
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Length:
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Test duration:
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Time test on:
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Time test off:
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Test pass:
- YES
- NO
- N/A
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Final connection type COUPLER / TOP TEE PE:
- 3/4 x 32mm EF COUPLER
- 1" x 32mm EF COUPLER
- 20mm x 32mm EF COUPLER
- 25mm x 32mm EF COUPLER
- 32mm x 32mm EF COUPLER
- 2"x 63mm EF COUPLER
- 63 mm x 63mm EF COUPLER
- 3" x 90mm EF COUPLER
- 90mm x 90mm EF COUPLER
- 4" x 125mm EF COUPLER
- 125mm x 125mm EF COUPLER
- 6" x 180mm EF COUPLER
- 180mm x 180mm EF COUPLER
- 32mm x 20mm EF TOP TEE
- 40mm x 32mm EF TOP TEE
- 55mm x 32mm EF TOP TEE
- 63mm x 32mm EF TOP TEE
- 63mm x 63mm HV EF TOP TEE
- 75mm x 32mm TOP TEE
- 75mm x 63mm HV EF TOP TEE
- 90mm x 32mm EF TOP TEE
- 90mm x 63mm HV EF TOP TEE
- 125mm x 32mm EF TOP TEE
- 125mm x 63mm HV EF TOP TEE
- 140mm x 32mm EF TOP TEE
- 140mm x 63mm HV EF TOP TEE
- 180mm x 32mm EF TOP TEE
- 180mm x 63mm HV EF TOP TEE
- 250mm x 32mm EF TOP TEE
- 250mm x 63mm HV EF TOP TEE
- 315mm x 32mm EF TOP TEE
- 315mm x 63mm HV EF TOP TEE
- 400mm x 32mm EF TOP TEE
- 400mm x 63mm HV EF TOP TEE
- 450mm x 32mm EF TOP TEE
- 450mm x 63mm HV EF TOP TEE
- 500mm x 32mm EF TOP TEE
- 500mm x 63mm HV EF TOP TEE
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Final connection type BRANCH SADDLE PE:
- 90 x 50
- 125 x 50
- 125 x 90
- 180 x 50
- 180 x 90
- 180 x 125
- 250 x 50
- 250 x 100
- 250 x 150
- 250 x 200
- 315 x 50
- 315 x 150
- 315 x 250
- 355 x 150
- 355x 250
- 400 x 150
- 400 x 250
- 450 x 150
- 450 x 250
- 500 x 150
- 500 x 250
- 630 x 150
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Final connection type CUT IN TEE PE:
- 63mm x 63mm EQUAL TEE
- 75mm x 75mm EQUAL TEE
- 90mm x 90mm EQUAL TEE
- 125mm x 125mm EQUAL TEE
- 140mm x 140mm EQUAL TEE
- 180mm x 180mm EQUAL TEE
- 250mm x 250mm EQUAL TEE
- 315mm x 315mm EQUAL TEE
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Final connection type METALLIC ST / BRANCH UPT
- 1" x 32mm ST
- 2" x 63mm TWO PART TEE
- 2" x 63mm two part tee C/W SPLIT COLLAR
- 3" x 80mm BRANCH UPT
- 4" x 80mm BRANCH UPT
- 6" x 100 BRANCH UPT
- 8" x 150mm BRANCH UPT
- 10" 200mm BRANCH UPT
- 12" x 250mm BRANCH UPT
- 14" x 300mm BRANCH UPT
- 16 x 300mm BRANCH UPT
- 18" x 300mm BRANCH UPT
- 24" x 300mm BRANCH UPT
- 36" x 300mm BRANCH UPT
- 48" x 300mm BRANCH UPT
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Address:
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Date:
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As laid drawing completed:
- YES
- NO
- N/A
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Was final connection LDF tested to prove soundness:
- YES
- NO
- N/A
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I herby certify that the gas supply undertaken at the above address is fit for purpose and meets all HSE Approved Codes of Practice and guidance notes. I certify that the pipe has passed the test in accordance with the appropriate IGE standards and that the pipes have been laid/ / altered / disconnected as described in the previous authorised design submission. Plans are attached. I am authorised to sign this certificate. Sign:
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Position of person signing this certificate:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
Test cert (mains)
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UNDER NO CIRCUMSTANCES IS THERE ANY PERSONNEL TO BE IN THE EXCAVATION DURING THE PRESSURISATION, TEST OR DEPRESSURISATION OF THE MAIN. PLEASE ACKNOWLEDGE THAT YOU WILL COMPLY WITH THIS INSTRUCTION.
- YES
- NO
- N/A
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Mains test certificate:
Mains test certificate
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Installer:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
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Network:
- NG
- SGN
- WWU
- NGN
- ESP
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Works carried out:
- New service
- New mains
- New mains & service
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Plot No / House No:
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Address:
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Date:
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As laid drawing complete:
- YES
- NO
- N/A
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Pressure tier:
- LOW
- MEDIUM
- INTERMEDIATE
- HIGH PRESSURE
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Size / Material of main:
- 63mm PE
- 75mm PE
- 90mm PE
- 125mm PE
- 180mm PE
- 250mm PE
- 315mm PE
- 400mm PE
- 1" Steel
- 2"Steel
- 3" Steel
- 4"Steel
- 6" Steel
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Test gauge type:
- Druck 705is
- 48" water gauge
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Serial number:
-
Test pressure:
-
Test duration:
-
Length:
-
Time test started after initial pressurisation and settle:
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Time test off
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Final connection BRANCH SADDLE PE:
- 90 x 50
- 125 x 50
- 125 x 90
- 180 x 50
- 180 x 90
- 180 x 125
- 250 x 50
- 250 x 100
- 250 x 150
- 250 x 200
- 315 x 50
- 315 x 150
- 315 x 250
- 355 x 150
- 355x 250
- 400 x 150
- 400 x 250
- 450 x 150
- 450 x 250
- 500 x 150
- 500 x 250
- 630 x 150
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Final connection METALLIC ST / BRANCH CONNECTION UPT:
- 1" x 32mm ST
- 2" x 63mm TWO PART TEE
- 2" x 63mm two part tee C/W SPLIT COLLAR
- 3" x 80mm BRANCH UPT
- 4" x 80mm BRANCH UPT
- 6" x 100 BRANCH UPT
- 8" x 150mm BRANCH UPT
- 10" 200mm BRANCH UPT
- 12" x 250mm BRANCH UPT
- 14" x 300mm BRANCH UPT
- 16 x 300mm BRANCH UPT
- 18" x 300mm BRANCH UPT
- 24" x 300mm BRANCH UPT
- 36" x 300mm BRANCH UPT
- 48" x 300mm BRANCH UPT
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Final connection EF COUPLER / TOP TEE PE
- 3/4 x 32mm EF COUPLER
- 1" x 32mm EF COUPLER
- 20mm x 32mm EF COUPLER
- 25mm x 32mm EF COUPLER
- 32mm x 32mm EF COUPLER
- 2"x 63mm EF COUPLER
- 63 mm x 63mm EF COUPLER
- 3" x 90mm EF COUPLER
- 90mm x 90mm EF COUPLER
- 4" x 125mm EF COUPLER
- 125mm x 125mm EF COUPLER
- 6" x 180mm EF COUPLER
- 180mm x 180mm EF COUPLER
- 32mm x 20mm EF TOP TEE
- 40mm x 32mm EF TOP TEE
- 55mm x 32mm EF TOP TEE
- 63mm x 32mm EF TOP TEE
- 63mm x 63mm HV EF TOP TEE
- 75mm x 32mm TOP TEE
- 75mm x 63mm HV EF TOP TEE
- 90mm x 32mm EF TOP TEE
- 90mm x 63mm HV EF TOP TEE
- 125mm x 32mm EF TOP TEE
- 125mm x 63mm HV EF TOP TEE
- 140mm x 32mm EF TOP TEE
- 140mm x 63mm HV EF TOP TEE
- 180mm x 32mm EF TOP TEE
- 180mm x 63mm HV EF TOP TEE
- 250mm x 32mm EF TOP TEE
- 250mm x 63mm HV EF TOP TEE
- 315mm x 32mm EF TOP TEE
- 315mm x 63mm HV EF TOP TEE
- 400mm x 32mm EF TOP TEE
- 400mm x 63mm HV EF TOP TEE
- 450mm x 32mm EF TOP TEE
- 450mm x 63mm HV EF TOP TEE
- 500mm x 32mm EF TOP TEE
- 500mm x 63mm HV EF TOP TEE
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Final connection CUT IN TEE PE
- 63mm x 63mm EQUAL TEE
- 75mm x 75mm EQUAL TEE
- 90mm x 90mm EQUAL TEE
- 125mm x 125mm EQUAL TEE
- 140mm x 140mm EQUAL TEE
- 180mm x 180mm EQUAL TEE
- 250mm x 250mm EQUAL TEE
- 315mm x 315mm EQUAL TEE
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Test pass:
- YES
- NO
- N/A
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Was final connection LDF tested on completion:
- YES
- NO
- N/A
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I herby confirm that this test was carried out to nationally recognised standards.
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Position of person signing this certificate:
- N SMART - multi skilled
- K AINSWORTH -multi skilled
- A MANSELL - service layer
Reinstatement
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Please record each excavation reinstatement required below:
Reinstatement
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Will the reinstatement company be required to excavate the temporary tarmac, top up stone, re compact and remove spoil from site.
- YES
- NO
- N/A
-
What weight of MOT TYPE 1 will be required from reinstatement company:
- 1/4 ton
- 1/2 ton
- 3/4
- 1ton
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Surface category or item required:
- CLASS 1
- CLASS 2
- CLASS 3
- CLASS 4
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Material:
- HRA
- 10 MM
- 6 MM
- Topsoil & seed
- Topsoil
- Concrete
- Block pavers
- Turf
- Specilist
- TAK Tile
- 2x2 slab
- 3x2 slab
- Bullnose kerb
- Radius kerb
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Depth:
- 80mm
- 100mm
- 250mm
- 375mm
- N/A
Site works compleation pictures
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Works complete picture
Site picture
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Add media
Client sign off
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Now that the works are complete please get the customer to sign below to confirm that they are satisfied with the works carried out.
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Has site been left clean and tidy in areas of our works
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Has a MPRN been fitted and filled in
- YES
- NO
- N/A
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MPRN Label in place on ECV
-
Has the ECV leaver, Wheel been fitted (this is RIDDOR reportable if not fitted)
- YES
- NO
- N/A
-
Has ECV on off tape been fitted:
- YES
- NO
- N/A
-
Picture of ECV:
-
Has collection of chapter 8 and unused fittings been arranged.
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Client to fill in below.
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Now that your gas connection is complete are you satisfied with the team and the works carried out. If remedial works are required please state what is required below in client comments.
- YES
- NO
- N/A
-
How satisfied are you overall:
- Very satisfied
- Satisfied
- Not satisfied
- Unhappy
- Very unhappy
- Would like a call from a director
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Client comments:
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Information / picture
-
Information / picture
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Client signature:
-
Date
Site visitors
-
Site visitors who have received a site induction:
Visitor
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Site visitor been given a site induction:
-
Add signature
