Form Center

2. Dealer
4. Address
6. City
7. State
8. Zip Code
10. Customer
11. Phone
13. Address
15. City
16. State
17. Zip Code
19. Completed Walk Through Visual Check
    -- Select One --BuildingHomeMobile HomeOther
21. Completed Walk Through Visual Check (Check One)

    1. Building
    2. Home
    3. Mobile Home
    4. Other
23. Physical Location
25. City
26. State
27. Zip Code
29. Tank
31. Manufacturer
33. Serial Number
34. Size
35. Distance from Tank to Bldg
37. Manufacturer
39. Serial Number
40. Size
41. Distance from Tank to Bldg
43. Regulator
45. Type
46. Manufacturer
48. Model #
49. Code Date
50. Lock-up Pressure
52. Type
53. Manufacturer
55. Model #
56. Code Date
57. Lock-up Pressure
59. Appliances
61. 1. Type of Appliance
62. Manufacturer
64. Vented
65. Pilot Safety System
66. Manual Shut-off
68. 2. Type of Appliance
69. Manufacturer
71. Vented
72. Pilot Safety System
73. Manual Shut-off
75. 3. Type of Appliance
76. Manufacturer
78. Vented
79. Pilot Safety System
80. Manual Shut-off
82. 4. Type of Appliance
83. Manufacturer
85. Vented
86. Pilot Safety System
87. Manual Shut-off
89. 5. Type of Appliance
90. Manufacturer
92. Vented
93. Pilot Safety System
94. Manual Shut-off
96. Capped Openings
97. Locations
99. Systems Leak Check
101. Test Pressure
102. Tank Pressure
103. Time Held
105. Pressure Check
107. Test Pressure
108. Tank Pressure
109. Time Held
111. DISCLAIMER
     This inspection covers LP-Gas (Propane) piping, fittings and equipment visible and accessible to Dealer's Representative and reflects the conditions existing on the date of the inspection. It does not cover latent or manufacturing defects, the internal workings of sealed equipment, structural components, or LP-Gas (Propane) products and cannot be construed to cover future defects ir unforseen happenings.
115. Read and initial.
117. I know how to turn off gas in case of emergency.
119. I have smelled propane and can detect its odor.
121. I have received "Duty to Warn" information.
123. I certify the number of appliances above is correct.
125. Comments
127. By typing my name and date below, I hereby acknowledge that as the customer I am responsible for the system past the LP gas container service valve and throughout the building and that a pressure test and/or leak test has been performed and the system was found to be leak free.
129. Customer Name
130. Date
132. By typing my name and date below, I certify that a pressure and/or leak test has been performed and the system was found to be leak free.
134. Dealer Representative Name
135. Date
Leave This Blank:


137. 1. Receive an email copy of this form.
138. Email address

     This field is not part of the form submission.

139. Submit

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