Gas Servicing Record

Title Page

Client details

Client/agent
Address
Date of works

Details of Gasfitter who carried out the work

Name
Registration/License

Details of supervising Gasfitter

Name
Registration/License

Signature of licensed gasfitter who carried out or supervised the work:

Signature

RESULT

Property Summary

Property Outcome

Has the gas safety check been carried out in accordance with AS/NZS 5016 & AS4575
Compliant or Non-Compliant
Is further action required?
Has a quote been supplied?

Fault detail summary (technician)

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GAS LINE TEST

Did the gas line pass it's leakage test?

AS4575 Appendix E #1

Appliance 1

Appliance 1
MAKE
MODEL
MODEL#
GAS TYPE
SERIAL#
DATE OF MANUFACTURE
CERTIFICATION BODY + NUMBER
SAFE
ACTION REQUIRED
1. Has the appliance been cleaned?
2. Is there evidence of gas product certification?
3. Is the appliance subject to any safety recall, prohibitions or notices?
4. Has the appliance been altered since manufacture in a manner which may render it unsafe?
5. Is the appliance certified for use in the location where it is installed and is it suitable for the connected gas supply?
6. Is the appliance installed in accordance with the relevant edition of AS/NZS 5601?
7. Is the appliance appropriately secured?
8. Is the appliance gastight? (Visual inspection and leakage test)
9. Is the flue cowl, chimney plate, flue terminal and flue (where accessible) in good condition and clear of obstruction?
10. Where applicable, does the appliance have an accessible means of electrical isolation?
11. Is the appliance regulator accessible for servicing and adjustment?
12. Where applicable, is the flue, or its surroundings, clear of signs of scorching or overheating?
13. Where applicable, is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at the roof penetration?
14. Is there any evidence of worn or damaged components?
15. Was there any build-up of dust or other foreign matter in or on the appliance that may affect correct operation?
16. Are flame sensor rods, ignition electrodes and thermocouples free of carbon deposits (i.e. soot)?
17. For appliances connected with a hose assembly, is the condition of the hose satisfactory?
18. Is the gas supply pressure to the appliance inlet adequate (1.13 or 2.75 kPa LPG) when all gas appliances are in operation?
19. Is the nominal burner pressure correct?
20. Is the ignition and re-ignition reliable and complete?
21. Where applicable, does the flame safeguard allow for flame establishment within the period specified in the appliance manufacturer’s instructions?
22. Where applicable, does the flame safeguard isolate the gas supply when there has been an interruption to the gas supply?
23. Does the appliance burner flame exhibit any flame abnormality?
24. For appliances with a turndown setting, does the burner flame remain stable when operated from the high to the low setting?
25. Is there any abnormal noise and/or vibration during the operation of the appliance?
26. Where applicable, are burner flames stable when opening and closing doors associated with the appliance or the installation?
27. Do control knobs and door handles become too hot to touch while the appliance is in operation?
28. Where applicable, are integral guards for space heaters adequately secured to the appliance and are they in good condition?
29. For heated water, has the PTR (pressure and temperature relief) valve been checked for correct operation?
30. Where applicable, is there any evidence of a cracked heat exchanger?
31. For open-flued appliances, does the appliance operate so that there is no spillage of combustion products in accordance with Appendix F?
32. Was a negative pressure identified at the appliance?
33. Did the appliance pass it's CO test?

AS4575 Appendix E #2

Appliance 2

Appliance 2
MAKE
MODEL
MODEL#
GAS TYPE
SERIAL#
DATE OF MANUFACTURE
CERTIFICATION BODY + NUMBER
SAFE
ACTION REQUIRED
1. Has the appliance been cleaned?
2. Is there evidence of gas product certification?
3. Is the appliance subject to any safety recall, prohibitions or notices?
4. Has the appliance been altered since manufacture in a manner which may render it unsafe?
5. Is the appliance certified for use in the location where it is installed and is it suitable for the connected gas supply?
6. Is the appliance installed in accordance with the relevant edition of AS/NZS 5601?
7. Is the appliance appropriately secured?
8. Is the appliance gastight? (Visual inspection and leakage test)
9. Is the flue cowl, chimney plate, flue terminal and flue (where accessible) in good condition and clear of obstruction?
10. Where applicable, does the appliance have an accessible means of electrical isolation?
11. Is the appliance regulator accessible for servicing and adjustment?
12. Where applicable, is the flue, or its surroundings, clear of signs of scorching or overheating?
13. Where applicable, is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at the roof penetration?
14. Is there any evidence of worn or damaged components?
15. Was there any build-up of dust or other foreign matter in or on the appliance that may affect correct operation?
16. Are flame sensor rods, ignition electrodes and thermocouples free of carbon deposits (i.e. soot)?
17. For appliances connected with a hose assembly, is the condition of the hose satisfactory?
18. Is the gas supply pressure to the appliance inlet adequate (1.13 or 2.75 kPa LPG) when all gas appliances are in operation?
19. Is the nominal burner pressure correct?
20. Is the ignition and re-ignition reliable and complete?
21. Where applicable, does the flame safeguard allow for flame establishment within the period specified in the appliance manufacturer’s instructions?
22. Where applicable, does the flame safeguard isolate the gas supply when there has been an interruption to the gas supply?
23. Does the appliance burner flame exhibit any flame abnormality?
24. For appliances with a turndown setting, does the burner flame remain stable when operated from the high to the low setting?
25. Is there any abnormal noise and/or vibration during the operation of the appliance?
26. Where applicable, are burner flames stable when opening and closing doors associated with the appliance or the installation?
27. Do control knobs and door handles become too hot to touch while the appliance is in operation?
28. Where applicable, are integral guards for space heaters adequately secured to the appliance and are they in good condition?
29. For heated water, has the PTR (pressure and temperature relief) valve been checked for correct operation?
30. Where applicable, is there any evidence of a cracked heat exchanger?
31. For open-flued appliances, does the appliance operate so that there is no spillage of combustion products in accordance with Appendix F?
32. Was a negative pressure identified at the appliance?
33. Did the appliance pass it's CO test?

AS4575 Appendix E #3

Appliance 3

Appliance 3
MAKE
MODEL
MODEL#
GAS TYPE
SERIAL#
DATE OF MANUFACTURE
CERTIFICATION BODY + NUMBER
SAFE
ACTION REQUIRED
1. Has the appliance been cleaned?
2. Is there evidence of gas product certification?
3. Is the appliance subject to any safety recall, prohibitions or notices?
4. Has the appliance been altered since manufacture in a manner which may render it unsafe?
5. Is the appliance certified for use in the location where it is installed and is it suitable for the connected gas supply?
6. Is the appliance installed in accordance with the relevant edition of AS/NZS 5601?
7. Is the appliance appropriately secured?
8. Is the appliance gastight? (Visual inspection and leakage test)
9. Is the flue cowl, chimney plate, flue terminal and flue (where accessible) in good condition and clear of obstruction?
10. Where applicable, does the appliance have an accessible means of electrical isolation?
11. Is the appliance regulator accessible for servicing and adjustment?
12. Where applicable, is the flue, or its surroundings, clear of signs of scorching or overheating?
13. Where applicable, is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at the roof penetration?
14. Is there any evidence of worn or damaged components?
15. Was there any build-up of dust or other foreign matter in or on the appliance that may affect correct operation?
16. Are flame sensor rods, ignition electrodes and thermocouples free of carbon deposits (i.e. soot)?
17. For appliances connected with a hose assembly, is the condition of the hose satisfactory?
18. Is the gas supply pressure to the appliance inlet adequate (1.13 or 2.75 kPa LPG) when all gas appliances are in operation?
19. Is the nominal burner pressure correct?
20. Is the ignition and re-ignition reliable and complete?
21. Where applicable, does the flame safeguard allow for flame establishment within the period specified in the appliance manufacturer’s instructions?
22. Where applicable, does the flame safeguard isolate the gas supply when there has been an interruption to the gas supply?
23. Does the appliance burner flame exhibit any flame abnormality?
24. For appliances with a turndown setting, does the burner flame remain stable when operated from the high to the low setting?
25. Is there any abnormal noise and/or vibration during the operation of the appliance?
26. Where applicable, are burner flames stable when opening and closing doors associated with the appliance or the installation?
27. Do control knobs and door handles become too hot to touch while the appliance is in operation?
28. Where applicable, are integral guards for space heaters adequately secured to the appliance and are they in good condition?
29. For heated water, has the PTR (pressure and temperature relief) valve been checked for correct operation?
30. Where applicable, is there any evidence of a cracked heat exchanger?
31. For open-flued appliances, does the appliance operate so that there is no spillage of combustion products in accordance with Appendix F?
32. Was a negative pressure identified at the appliance?
33. Did the appliance pass it's CO test?

AS4575 Appendix E #4

Appliance 4

Appliance 4
MAKE
MODEL
MODEL#
GAS TYPE
SERIAL#
DATE OF MANUFACTURE
CERTIFICATION BODY + NUMBER
SAFE
ACTION REQUIRED
1. Has the appliance been cleaned?
2. Is there evidence of gas product certification?
3. Is the appliance subject to any safety recall, prohibitions or notices?
4. Has the appliance been altered since manufacture in a manner which may render it unsafe?
5. Is the appliance certified for use in the location where it is installed and is it suitable for the connected gas supply?
6. Is the appliance installed in accordance with the relevant edition of AS/NZS 5601?
7. Is the appliance appropriately secured?
8. Is the appliance gastight? (Visual inspection and leakage test)
9. Is the flue cowl, chimney plate, flue terminal and flue (where accessible) in good condition and clear of obstruction?
10. Where applicable, does the appliance have an accessible means of electrical isolation?
11. Is the appliance regulator accessible for servicing and adjustment?
12. Where applicable, is the flue, or its surroundings, clear of signs of scorching or overheating?
13. Where applicable, is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at the roof penetration?
14. Is there any evidence of worn or damaged components?
15. Was there any build-up of dust or other foreign matter in or on the appliance that may affect correct operation?
16. Are flame sensor rods, ignition electrodes and thermocouples free of carbon deposits (i.e. soot)?
17. For appliances connected with a hose assembly, is the condition of the hose satisfactory?
18. Is the gas supply pressure to the appliance inlet adequate (1.13 or 2.75 kPa LPG) when all gas appliances are in operation?
19. Is the nominal burner pressure correct?
20. Is the ignition and re-ignition reliable and complete?
21. Where applicable, does the flame safeguard allow for flame establishment within the period specified in the appliance manufacturer’s instructions?
22. Where applicable, does the flame safeguard isolate the gas supply when there has been an interruption to the gas supply?
23. Does the appliance burner flame exhibit any flame abnormality?
24. For appliances with a turndown setting, does the burner flame remain stable when operated from the high to the low setting?
25. Is there any abnormal noise and/or vibration during the operation of the appliance?
26. Where applicable, are burner flames stable when opening and closing doors associated with the appliance or the installation?
27. Do control knobs and door handles become too hot to touch while the appliance is in operation?
28. Where applicable, are integral guards for space heaters adequately secured to the appliance and are they in good condition?
29. For heated water, has the PTR (pressure and temperature relief) valve been checked for correct operation?
30. Where applicable, is there any evidence of a cracked heat exchanger?
31. For open-flued appliances, does the appliance operate so that there is no spillage of combustion products in accordance with Appendix F?
32. Was a negative pressure identified at the appliance?
33. Did the appliance pass it's CO test?