Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Ticket Number
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Appliance Location
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Appliance Number
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Burner Number
Burner Operation
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Is there a burner?
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CO2 % High
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CO2 % Low
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Co PPM High
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Co PPM Low
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CO/Co2 Ratio High
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CO/Co2 Ratio Low
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Flue Gas Temp High
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Flue Gas Temp Low
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Boiler Lockout Tested
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Combustion Efficiency
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Burner Pressure M/bar
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Inlet Gas Pressure M/bar
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Gas Rate
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Is there another burner?
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CO2 % High
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CO2 % Low
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Co PPM High
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Co PPM Low
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CO/Co2 Ratio High
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CO/Co2 Ratio Low
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Flue Gas Temp High
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Flue Gas Temp Low
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Boiler Lockout Tested
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Combustion Efficiency
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Burner Pressure M/bar
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Inlet Gas Pressure M/bar
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Gas Rate
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Is there another burner?
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Type of system
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Flueing
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Interlock Checked?
Safety Check
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Electrical Installation
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Electrical Installation
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Safety Valve PSI/Bar
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Pipework Gas
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Pipework Water
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Flue
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Flue Termination
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ECV (Checked)
Appliance Checks
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Boiler Door Opened
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Burner
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Heat Exchanger
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Dry Run Test
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Electrics
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Boiler Controls
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Ignition
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Water Ways
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Fan
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Flame Picture
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Operation of Flue
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Flue Flow Test
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Spillage Test
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Safety Devices
Ventilation Requirements
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All responses are cm2
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Ventilation H/L cm2
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Ventilation L/L cm2
Gas Pipework
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Let-by test from Service Valve
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Tightness test from Service Valve
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Let-by test from ECV
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Tightness test pipework
Result
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Is this application safe for use?
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Raise action to Commercial Gas Team Manager and attach label as evidence
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Has the equipment been installed to the relevant standard/manufacturers instructions?
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Is further work required?
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Gas Operative Signature
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Works Number
Approval
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Date and time of approval
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Approver's signature
