Customer / Job Details

Account Name

Postal Address

Name of Client

Site Address

Customer Description

Contact

Description of Job

Date Received
Date Started
Date Completed

Order Number

Quote/Estimate

Tax Invoice Number

Home

Work

Mobile

Mobile 2

Fax

Email

Customer Declaration (Optional)

I authorise this contractor to carry out the work as detailed on this form. I understand that no significant additional work will be undertaken without my authorisation and I accept the terms and conditions. I will settle payment by:

Customers Signature

Safety Verification, Pipework, Combustion Related Test

Safety Verification Of Gas System / Supply

Suitable Fittings

Available Flow Rate mj/hr

Drop Test kpa

Gas Tightness

Gas Pressure kpa

Meter

Pipework

Pressure Test

Pressure kpa

Installation Test kpa

Combustion Related Test

CO/CO2 %

Flue Temp 300 C

Ventilation

CO ppm

Flue Material C

Flue Condition

Gas appliance used for intended purpose

Reason

OSHE ~ Hazards Identifaction & Site Safety Requirements

Temperature - Climate Conditions

Action

Combustibles - Fire Resistant Material - Flammable Gas Signage

Action

Visitors - Induct all visitors & contractors with induction cards

Action

Moving Vehicles - Keep clear - Stay visible to operator - Signage

Action

Ladders - Only commercial grade in good condition - Used correctly

Action

Scaffolding - Installed correctly - Regularly checked - Certified

Action

Falls from height - Use fall protection - Scaffolding in place - Height notifiable work

Action

Overhead Work - Secure tools from falling - Visitors keep clear

Action

Electricity in use - Use RCD's - Check leads regularly - Tagged

Action

Powertools in use - Check in good condition - Use correctly - Tagged

Action

Excavations - Cover holes - Secure site - Stay visible to operator

Action

Tripa/Slipa - Keep site tidy - Use waste bin on site

Action

Illness/Disease - Toilet on site - Running water on site

Action

First Aid Certificate - Current - ABC's

Action

Gas Set/Mapp Gas - Oxygen - Acetylene - Shut off when not in use

Action

First Aid Kit - Upgraded - Where is it?

Action

Service Procedure

Isolate gas supply and/or electrical supply to the appliance

Remove gas control knobs and any panels from the gas appliance to gain access to gas valves, burners and pilot assembly

Clean inspirators primary air inlet Clean all openings from dust,spider webs etc.

Remove burner and clean all burner ports, check for corrosion

Remove pilot burner & clean both pilot injector and main burner injector

Reassemble both pilot burner and main burner

Visually check wires and electrical connections

Test all electrical safety interlocks for sound operation

Check ignitor probe for positioning and quick ignition

Check flame rectification probe for correct milliamp signal and positioning

Check thermocouple and/or thermopile for correct millivolt and positioning

Visually check flame picture and flame stability, check that aeration is correct

Check dynamic pressure and adjust if necessary

Leak test gas pipe work and controls for soundness

Which test did you use?

Check gas control valves for correct operation, physical damage and general wear and tear, clean any gas filters gauze or fabric

Ensure the draught diverter is clear of obstructions and check for draught using smoke while gas appliance is still cold

Check for condition of flue system and gas terminal to ensure that it has not been affected by any foreign or organic matter clear any flue blockage

Check the gas appliance position in relation to any combustible materials

Check room size for correct ventilation requirements against ASNZS 5601:2010

Ensure the room enclosure is not used to store flammable goods or chemicals, as flames will contaminate the combustion air and create toxic or deadly chemical reactions

Locate the date and ensure that the gas appliance is suitable for its intended use

Recommission the appliance in accordance with ASNZS 5601:2010

Gas Appliance Markings

Make

1

2

3

4

Model

1

2

3

4

Serial Number

1

2

3

4

Isolating Valve

1

2

3

4

Clearances

1

2

3

4

Flue Type

1

2

3

4

Flue Position

1

2

3

4

Appliance Pressure

1

2

3

4

Appliance Pressure High

1

2

3

4

Appliance Pressure Low

1

2

3

4

Input Rating

1

2

3

4

Commissioned

1

2

3

4

Ventilation

1

2

3

4

Combustion

1

2

3

4

Seismic Restraint

1

2

3

4

Date of Install

Gas Certification Number

Category

Type

Gas Supplier

Labelled

Test Pressure

Test Time

Nil Leak Tolerance

Regulators

Auto

Manual

LP-HP

First Stage

Second Stage

Appliance Reg

Ventilation Requirements

For further information see ASNZS 5601:2010, Ventilation requirements, parts 1 & 2
In brief:
- Ventilation shall ensure proper operation of the gas appliance and flueing system and maintain safe ambient conditions
- Where a gas appliance is installed in a room, that room shall be ventilated
- Where the total input of open flued appliance exceeds 3MJ/hr for each cubic metre of room volume, the area shall be ventilated
- Where the total input of open flued appliance does not exceed 3MJ/hr per cubic metre of room volume, the required air may be provided by adventitious openings, ie gaps around doors and windows
- to establish whether the required air is to be provided by adventitious openings or additional openings. Calculate the total input of the gas appliance or appliance in the room in MJ/hr and divide by the room volume in cubic metres

Total gas input MJ/HR

Divided by

Room Volume m3 L x W x H

= m3

= MJ per cubic metre

Natural ventilation. Two permanent openings shall be provided each with a minimum free area as calculated using:
A = FxT formula
A = Minimum free area mm square
F = Factor given in table 13
T = Total gas consumption of all gas appliances

Adventitious Ventilation

Additional Ventilation Required

Checked

Initials

Commissioning and Final Testing Checks (normal operating conditions)

Leak Test

OK

Comments

Gas Consumption

OK

Comments

Operation

OK

Comments

Reignition

OK

Comments

Flame Picture

OK

Comments

Temperature Hazards

OK

Comments

Safeguard System

OK

Comments

Safety Shut Down

OK

Comments

Visually Check Wires

OK

Comments

Earth Continuity Test 3 Volts less than 0.5 ohm

Comments

Insulation Resistance 500 Volts less than 1M ohm

Comments

Polarity Test

Comments

Troubleshooting and Fault Finding

Have you remedied the ...

What is the Root Cause of this failure or breakdown?

Completion of Work & Job Card

Signature of Technician
Date Signed
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.