Title Page
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Project No.
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Address
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Conducted on
Manufacturer
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Manufacturer
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Model
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Year of Manufacture
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Photo of Model No.
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Flued or Unflued?
Service
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Technician
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Location
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Completed Clean and Adjust Room Heater
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Clean Out Filter
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Test Gas Pressure
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KPA
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Images
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Test Carbon Monoxide
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Carbon Monoxide Reading - CO
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Photo of Reading
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Clean Pilot Light
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Check Ventilation
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Compliant?
- Complies with Gas Standards AS/NZ 5601
- Non Compliant
- Requires variation
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Is any Damage evident?