Robertson FM Gas Safe Test

• Document No.

• Client / Site

• Conducted on

  Date

• Gas Safe Engineer

• Gas Safe Engineer Registration Number

• Location
  Address

Details/ Information

• Company Registration number - 232501
  Robertson Facilities Management
  Robertson House
  Castle Business Park
  Stirling, FK9 4TZ
  Tel: 01786 431600

  

• Notice to Service Engineers:
  When completing the safety reports, reference should be made to Notes for completion, your Safety Pocket Card, manufacturers instructions and relevant Company Procedures

• Notice to Landlords:
  This inspection is for gas safety purposes only and is accordance with current GAS safety installation & use regulations. Flues were inspected visually and checked for satisfactory evacuation of products of combustion. A detailed internal inspection of flue integrity, construction and lining has NOT been carried out

• Gas Appliance

Appliance

Appliance

• Location

• Make/ Description

• Model Reference

• Landlord Owned

  Yes

  No

  N/A

• Flue Type? OF/ RS/ FL

  OF

  RS

  FL

• Inspected?

  Yes

  No

  N/A

• Operating Pressure (WG/mb)

• Heat Input (KWH/ BTU)

• Safety Devices<br>(Pass or Fail?)

  PASS

  FAIL

  N/A

• Ventilation Installation Correct?

  Yes

  No

  N/A

• Flue Flow Test

  PASS

  FAIL

  N/A

• Spillage Test

  PASS

  FAIL

  N/A

• Visual Condition

  PASS

  FAIL

  N/A

• Termination Satisfactory?

  Yes

  No

  N/A

• Appliance Safe to Use?

  Yes

  No

  N/A

• Details of any faults or remedial action taken

• Warning Notice?

  Yes

  No

  N/A

Combustion BEFORE Service

• Combustion CO

• Combustion CO2 %

• Combustion RATIO

Combustion AFTER Service

• Combustion CO

• Combustion CO2 %

• Combustion RATIO

• ECD

  PASS

  FAIL

  N/A

Installation Observations

• Emergency Control Accessible

  Yes

  No

  N/A

• Adequate Cross bonding present?

  Yes

  No

  N/A

• Manufacturer's information on site?

  Yes

  No

  N/A

• Works Completed?

  Yes

  No

  N/A

Fuel Pipework & tightness

• Pipework Strength Tested?

  Yes

  No

  N/A

• Pipework tightness tested

  Yes

  No

  N/A

• Appliance pipework tight?

  Yes

  No

  N/A

• Pipework Secure and correct size?

  Yes

  No

  N/A

Summary

• Installation left safe for use?

  Yes

  No

  N/A

• Is installation NTCS?

  Yes

  No

  N/A

• Warning Notices Issued?

  Yes

  No

  N/A

• RIDDOR Reportable?

  Yes

  No

  N/A

• Gas Engineer Signature

  Sign

• Received on behalf of owner/ landlord (Sign)

  Sign