Gas Servicing

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

• Optional Template

  Yes

  No

  N/A

• How to complete this form:

• Please ensure to:

• How to submit your form:

  Yes

  No

  N/A

• Please fill out your form, sign and submit your form

Victorian Building Authority

Section 1

DETAILS OF GASFITTER WHO CARRIED OUT THE WORK

• First name

• Last name

• Registration/Licence number

Section 2

DETAILS OF SUPERVISING GASFITTER WHO SUPERVISED THE WORK

• Last name

• First name

• Licence number

Section 3

DETAILS OF VENDOR

• Business name of vendor in financial transaction for provision of the work

  Yes

  No

  N/A

• ABN of vendor

DETAILS OF GASFITTING WORK

• Date of work carried out

  Date

• Address at which the work was carried out

• Details of work carried out, including any adjustments, replacements, testing and repairs

• (Attach a separate sheet of paper if remedial action cannot fit within box provided)

  Yes

  No

  N/A

• SD-FRM-029 VBA Gas Service

  Yes

  No

  N/A

• Record Form V2, September 2022

  Yes

  No

  N/A

Victorian Building Authority

Section 4

• DETAILS OF APPLIANCE ON WHICH THE WORK WAS CARRIED OUT

Appliance 1

Appliance 2

• Make

• Model

• Model number

• Gas type

  Yes

  No

  N/A

Section 5

AS 4575 APPENDIX E

Appliance 1

Appliance 2

• 1. Has the appliance been cleaned?

  Yes

  No

  N/A

• 2. Is there evidence of gas product certification?

  Yes

  No

  N/A

• 3. Is the appliance subject to any safety recall, prohibitions or notices?

  Yes

  No

  N/A

• 6. Is the appliance installed in accordance with the relevant edition of AS/

  Yes

  No

  N/A

• NZS 5601?

  Yes

  No

  N/A

• 7. Is the appliance appropriately secured?

  Yes

  No

  N/A

• 8. Is the appliance gastight? (Visual inspection and leakage test)

  Yes

  No

  N/A

• 10. Where applicable, does the appliance have an accessible means of electrical isolation?

  Yes

  No

  N/A

• 11. Is the appliance regulator accessible for servicing and adjustment?

  Yes

  No

  N/A

• SD-FRM-029 VBA Gas Service

  Yes

  No

  N/A

• Record Form V2, September 2022

  Yes

  No

  N/A

Victorian Building Authority

Section 5 Continued

Appliance 1

Appliance 2

• 14. Is there any evidence of worn or damaged components?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• 19. Is the nominal burner pressure correct?

  Yes

  No

  N/A

• 20. Is the ignition and re-ignition reliable and complete?

  Yes

  No

  N/A

• 23. Does the appliance burner flame exhibit any flame abnormality?

  Yes

  No

  N/A

• 32. Was a negative pressure identified at the appliance? (See 'a' below)

  Yes

  No

  N/A

• SD-FRM-029 VBA Gas Service

  Yes

  No

  N/A

• Record Form V2, September 2022

  Yes

  No

  N/A

Victorian Building Authority

Section 5 Continued

Appliance 1

Appliance 2

• 33. Combustion products detection equipment: Instrument details

  Yes

  No

  N/A

• 34. Instrument calibration date

  Yes

  No

  N/A

• 35. Installation details: Number and location of exhaust fans

• 36. Combustion products spillage (CO Concentration (ppm) and/or

  Yes

  No

  N/A

• CO2 (%)) if applicable (see 'b' below)

  Yes

  No

  N/A

• 37. Background check (appliance off)

  Yes

  No

  N/A

• 40. Final reading at the appliance on high available at: ESV launches 24/7 hotline for gasfitters –Energy Safe Victoria

  Yes

  No

  N/A

DECLARATION & SIGNATURE

• I declare that the information in the record is not false or misleading in any material detail

  Yes

  No

  N/A

• Date of declaration:

  Date

• SD-FRM-029 VBA Gas Service

  Yes

  No

  N/A

• Record Form V2, September 2022

  Yes

  No

  N/A

Victorian Building Authority

• Privacy collection notice

  Yes

  No

  N/A

• How the VBA uses and discloses your personal information

• The Victorian Building Authority (VBA) is collecting your personal information (including any images or photographs information requested in this form, the VBA may be unable to receive and process your gas servicing record. The

• VBA may also use such information for the following purposes:

• (a)To enable the VBA to meet its statutory obligations, functions and perform its operational requirements

  Yes

  No

  N/A

• (b)Researching and assessing the merit and impact of proposed regulatory reforms and to assist in the

  Yes

  No

  N/A

• development and delivery of services by the VBA (whether to you personally or a member of the public)

  Yes

  No

  N/A

• (c)Law enforcement by the VBA or other regulatory bodies, including prosecutions or disciplinary action against

  Yes

  No

  N/A

• you if required

  Yes

  No

  N/A

• (d)Maintaining disciplinary and licensing and registration registers for building and plumbing practitioners

  Yes

  No

  N/A

• (published on the VBA’s website)

  Yes

  No

  N/A

• (e)Such other purposes as required by law or authorised under the privacy legislation

  Yes

  No

  N/A

• The VBA may also share your personal information with third parties including, but not limited to, different business units within the VBA, Energy Safe Victoria, the Building Appeals Board, Consumer Affairs Victoria, the Victorian

• The Gas Safety (Gas Installation) Regulations 2018 requires the submission of certain information to the VBA

• Not providing all or part of the information requested may breach those regulations

  Yes

  No

  N/A

• SD-FRM-029 VBA Gas Service Record

  Yes

  No

  N/A

• Form V2, September 2022. End of For

  Yes

  No

  N/A