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Name

Address

City

State

Zip Code

Phone(Home)

Phone(Work)

Date of Inspection

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

Account #

WO/Invoice #

License #

Branch/Location

File Name (Will be used as .PDF file)
Equipment Type	None Boiler Central Heating Clothes Dryer Convection Oven Cooktop Fireplace/Insert Furnace Generator Pool Heater Grill Lighting Range Room/Space Heater Spa Heater Water Heater Other Unknown	None Boiler Central Heating Clothes Dryer Convection Oven Cooktop Fireplace/Insert Furnace Generator Pool Heater Grill Lighting Range Room/Space Heater Spa Heater Water Heater Other Unknown	None Boiler Central Heating Clothes Dryer Convection Oven Cooktop Fireplace/Insert Furnace Generator Pool Heater Grill Lighting Range Room/Space Heater Spa Heater Water Heater Other Unknown	None Boiler Central Heating Clothes Dryer Convection Oven Cooktop Fireplace/Insert Furnace Generator Pool Heater Grill Lighting Range Room/Space Heater Spa Heater Water Heater Other Unknown	None Boiler Central Heating Clothes Dryer Convection Oven Cooktop Fireplace/Insert Furnace Generator Pool Heater Grill Lighting Range Room/Space Heater Spa Heater Water Heater Other Unknown
Manufacturer
Year Manufactured
Model Number
Serial Number
Fuel	None Propane Oil Natural Gas Other	None Propane Oil Natural Gas Other	None Propane Oil Natural Gas Other	None Propane Oil Natural Gas Other	None Propane Oil Natural Gas Other
BTU’s (Maximum Input)
Manual Shutoff Valve	None OK OK Installed Requires CA	None OK OK Installed Requires CA	None OK OK Installed Requires CA	None OK OK Installed Requires CA	None OK OK Installed Requires CA
Sediment Trap	None OK OK Installed Requires CA N/A	None OK OK Installed Requires CA N/A	None OK OK Installed Requires CA N/A	None OK OK Installed Requires CA N/A	None OK OK Installed Requires CA N/A
Burner(s) Condition	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A
Combustion Chamber Condition	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A	None OK Orange Tag Requires CA Needs Cleaning N/A
Control/Pilot Safety System	None OK OK-Electronic OK-Pilot Orange Tag N/A	None OK OK-Electronic OK-Pilot Orange Tag N/A	None OK OK-Electronic OK-Pilot Orange Tag N/A	None OK OK-Electronic OK-Pilot Orange Tag N/A	None OK OK-Electronic OK-Pilot Orange Tag N/A
Venting System	None OK 7 Day Notice 14 Day Notice Orange Tag Requires CA N/A	None OK 7 Day Notice 14 Day Notice Orange Tag Requires CA N/A	None OK 7 Day Notice 14 Day Notice Orange Tag Requires CA N/A	None OK 7 Day Notice 14 Day Notice Orange Tag Requires CA N/A	None OK 7 Day Notice 14 Day Notice Orange Tag Requires CA N/A
Combustion Air	None OK OK Room Air OK Outside Air OK Direct Vent Orange Tag Requires CA N/A	None OK OK Room Air OK Outside Air OK Direct Vent Orange Tag Requires CA N/A	None OK OK Room Air OK Outside Air OK Direct Vent Orange Tag Requires CA N/A	None OK OK Room Air OK Outside Air OK Direct Vent Orange Tag Requires CA N/A	None OK OK Room Air OK Outside Air OK Direct Vent Orange Tag Requires CA N/A
Taken Out of Service	None Yes No	None Yes No	None Yes No	None Yes No	None Yes No
Taken Out of Svc or Operation (Tag #)

CONTAINER CHECK

Serial No.	Tag / Tank ID	Container Type		Size	Tank %	Manufacturer	Mfr. Date	Requal Date/Type
		ASME/DOT	AG/UG/AGUG					DOT Cylinders Only
		ASME DOT OTHER	AG UG AGUG
		ASME DOT OTHER	AG UG AGUG
		ASME DOT OTHER	AG UG AGUG
		ASME DOT OTHER	AG UG AGUG
		ASME DOT OTHER	AG UG AGUG

Container			Relief Valve
Foundation	Condition	Location	Condition	Date	Cap	Leak Test
N/A OK Requires CA	New OK/Good Fair Requires CA Requires CA-Needs Cleaning Requires CA-Needs Painting	OK Requires CA	OK Requires CA		OK Requires CA	OK Requires CA
N/A OK Requires CA	New OK/Good Fair Requires CA Requires CA-Needs Cleaning Requires CA-Needs Painting	OK Requires CA	OK Requires CA		OK Requires CA	OK Requires CA
N/A OK Requires CA	New OK/Good Fair Requires CA Requires CA-Needs Cleaning Requires CA-Needs Painting	OK Requires CA	OK Requires CA		OK Requires CA	OK Requires CA
N/A OK Requires CA	New OK/Good Fair Requires CA Requires CA-Needs Cleaning Requires CA-Needs Painting	OK Requires CA	OK Requires CA		OK Requires CA	OK Requires CA
N/A OK Requires CA	New OK/Good Fair Requires CA Requires CA-Needs Cleaning Requires CA-Needs Painting	OK Requires CA	OK Requires CA		OK Requires CA	OK Requires CA

System Type

Integral Two Stage Three Stage

Juristictional Account

YES NO UNKOWN

Uncapped Gas Line

YES NO

Re-capped Gas Line

YES NO N/A

PIPING				REGULATOR(S)
	Material	Size	Cover / Protection		MFR.	Model Number	Date Code	Condition	Vent Position	How Protected
Integral	Copper Tubing Black Iron Pipe Corrugated Steel Plastic Other	1/8 1/4 3/8 1/2 5/8 3/4 7/8	OK Requires CA	Integral	REGO Fisher Kosan Maxitrol Marshall Excelsior Other			New OK OK Installed Orange Tag	OK 4 O'Clock 5 O'Clock 6 O'Clock 7 O'Clock 8 O'Clock Side Down Requires CA	OK Under Cover Drip Lip Cap Requires CA
1st Stage				1st Stage
2nd Stage				2nd Stage
3rd Stage				3rd Stage

CSST TRACKING

Accessible

YES NO

Installed Properly

YES NO

Bonded

YES NO

Comment

System Type

System Leak Check

Pressure Test(10 Minutes)

System Operation Tests

Tank/Start Pressure

End Pressure

Start Time

End Time

Start Pressure

End Pressure

Start Time

End Time

Flow Pressure Test

Lock-Up Pressure Test

Integral/1st

WC PSI

WC PSI

WC PSI

WC PSI

2nd Stage

WC PSI

WC PSI

WC PSI

WC PSI

3rd Stage

WC PSI

WC PSI

WC PSI

WC PSI