• Date

  • Name & address


  • Type of appliance

  • Make & model of appliance

  • Flue type

  • Visual condition/termination of appliance/flue

  • Terminal guard fitted

  • Flue flow test

  • Spillage test

  • Ventilation

  • Flame picture

  • Inlet pressure

  • Burner pressure

  • Gas rating results

  • Combustion analysis reading

  • Appliance safe to use

  • Condition/efficiency of appliance 0 = poor 10 = excellent

  • Recommend replacement of appliance

Gas pipe work / meter

  • Gas pipe/meter satisfactory

  • Tightness test satisfactory

  • LDF used on test nipples


  • Earth bonding satisfactory

  • RCD fuse box fitted

Additional information

  • Comments / extra details

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