Gas safety inspection

• Conducted on

  Date

• Prepared by

• Location
  Address

• Is the installation gastight in accordance with AS/NZS5601.1?

  Yes

  No

  N/A

• Is the appliance and its components accessible for servicing and adjustment?

  Yes

  No

  N/A

• Where required by AS/NZS5601.1 is an isolation valve provided at the inlet connection of the appliance?

  Yes

  No

  N/A

• Is the appliance and its installation electrically safe? (Note: Electrical safety is confirmed by checking the electrical supply is isolated, checking earth continuity, checking insulation resistance (where applicable) and using bonding straps if disconnecting an appliance)

  Yes

  No

  N/A

• Is there evidence of certification? (AGA, SAI -Global, IAPMO, Global-Mark or BSI). (Record in the observations table if there is no evidence of certification).

  Yes

  No

  N/A

• Where applicable are gas appliances including cookers adequately restrained from tipping over?

  Yes

  No

  N/A

• Is the room ventilation adequate for the installed appliances? (consider installation and building date for applicable requirements)

  Yes

  No

  N/A

• Where visible are clearances from combustible surfaces in accordance with the installation instructions and AS/NZS5601.1?

  Yes

  No

  N/A

• Where applicable is the cowl, chimney plate or flue terminal in good condition and clear of obstruction?

  Yes

  No

  N/A

• Where applicable is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at roof penetration?

  Yes

  No

  N/A

• Where applicable is the flue, or its surroundings, clear of signs of scorching or overheating?

  Yes

  No

  N/A

Appliance servicing

• Where applicable is the heat exchanger in good condition (test for spillage of combustion products

  Yes

  No

  N/A

• Has the appliance been cleaned of dust and debris (e.g. burner, pilot, fan, filters, air intake)?

  Yes

  No

  N/A

• Are gas supply and burner operating pressures correct? (Note: All appliances must be operating)

  Yes

  No

  N/A

• Is the appliance clean of dust and debris (e.g. burner, pilot, fan, filters, air intake)

  Yes

  No

  N/A

• Are burner flames normal? (i.e. no evidence of flame lifting, floating, yellow tipping or sooting)

  Yes

  No

  N/A

• Is the appliance operating correctly including safety devices such as pressure and temperature relief valves?

  Yes

  No

  N/A

• Is the installation gastight in accordance with AS/NZS5601.1?

  Yes

  No

  N/A

• Is the appliance and its components accessible for servicing and adjustment?

  Yes

  No

  N/A

• Where required by AS/NZS5601.1 is an isolation valve provided at the inlet connection of the appliance?

  Yes

  No

  N/A

• Is the appliance and its installation electrically safe? (Note: Electrical safety is confirmed by checking the electrical supply is isolated, checking earth continuity, checking insulation resistance (where applicable) and using bonding straps if disconnecting an appliance)

  Yes

  No

  N/A

• Is there evidence of certification? (AGA, SAI -Global, IAPMO, Global-Mark or BSI). (Record in the observations table if there is no evidence of certification).

  Yes

  No

  N/A

• Where applicable are gas appliances including cookers adequately restrained from tipping over?

  Yes

  No

  N/A

• Is the room ventilation adequate for the installed appliances? (consider installation and building date for applicable requirements)

  Yes

  No

  N/A

• Where visible are clearances from combustible surfaces in accordance with the installation instructions and AS/NZS5601.1?

  Yes

  No

  N/A

• Where applicable is the cowl, chimney plate or flue terminal in good condition and clear of obstruction?

  Yes

  No

  N/A

• Where applicable is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at roof penetration?

  Yes

  No

  N/A

• Where applicable is the flue, or its surroundings, clear of signs of scorching or overheating?

  Yes

  No

  N/A

Appliance 2 servicing

• Where applicable is the heat exchanger in good condition (test for spillage of combustion products

  Yes

  No

  N/A

• Has the appliance been cleaned of dust and debris (e.g. burner, pilot, fan, filters, air intake)?

  Yes

  No

  N/A

• Are gas supply and burner operating pressures correct? (Note: All appliances must be operating)

  Yes

  No

  N/A

• Is the appliance clean of dust and debris (e.g. burner, pilot, fan, filters, air intake)

  Yes

  No

  N/A

• Are burner flames normal? (i.e. no evidence of flame lifting, floating, yellow tipping or sooting)

  Yes

  No

  N/A

• Is the appliance operating correctly including safety devices such as pressure and temperature relief valves?

  Yes

  No

  N/A

• Are cylinders installed on a firm, level and non-combustible base, and not resting on soil?

  Yes

  No

  N/A

• Are LP Gas cylinders suitably restrained and have compliant clearances?

  Yes

  No

  N/A

• Are hoses, pigtail and fittings in good condition and not degraded or work hardened?

  Yes

  No

  N/A

• Are pressure regulators correctly fitted, orientated, set and complete?

  Yes

  No

  N/A

Appliance one

• Negative pressure test (open flued appliances only) - Was there a negative pressure?

  Yes

  No

  N/A

• Spillage test - Was there spillage of combustion products?

  Yes

  No

  N/A

Appliance two

• Negative pressure test (open flued appliances only) - Was there a negative pressure?

  Yes

  No

  N/A

• Spillage test - Was there spillage of combustion products?

  Yes

  No

  N/A

Appliance 3

• Negative pressure test (open flued appliances only) - Was there a negative pressure?

  Yes

  No

  N/A

• Spillage test - Was there spillage of combustion products?

  Yes

  No

  N/A

Dangerous gas installations

• Gas Safety (Gas Installation) Regulations 2018, Part 3, Division 3, Section 21 1. If a person carrying out gasfitting work on a gas installation becomes aware of a danger arising from a defect in the gas installation, the person must without delay— a) take all steps that are necessary to make the installation safe; and b) notify the owner of the gas installation and the occupier of the premises in which the installation is situated of the defect. 2. Sub regulation (1)(a) does not apply if the person is unable, or it is unreasonable for the person, to take the necessary steps to make the gas installation safe. 3. If the person carrying out the gasfitting work is unable, or it is unreasonable for the person, to make the gas installation safe, he or she must, without delay, notify Energy Safe Victoria and— a) if the gas installation uses natural gas, the gas distribution company which supplies that gas to the gas installation of the defect; or b) if the gas installation uses LPG, the gas retailer which supplies that gas to the gas installation of the defect. O

  Sign

• Details of observations and identified faults<br>Note: Include reference to a Compliance Certificate number if applicable

  Yes

  No

  N/A

• Action to be taken?

  Yes

  No

  N/A

Declaration

• I, being the person responsible for the inspection of the identified gas appliances or installations in the rental property or rooming house, particulars of which are described here, having exercised reasonable skill and care when carrying out the inspection, hereby declare on the date of inspection that the information in this report, including the observations and recommendations, provides an accurate assessment of the condition of the gas appliances or installations in the rental property or rooming house taking into account the stated extent of the installation and the limitations of the inspection and testing.<br>I further declare that in my judgment, the said appliance(s) and corresponding installation(s) is/are:

  Compliant

  Non-Compliant

  Unsafe

• Gas license number

• Gas license holder name

• Company address

• Signature

  Sign

• Next inspection due

  Date