PERMIT DOCUMENTS VGASCheck _ l 6 zips/6
Gas System Check 14 02 6 9
Account umber: Invoice Number:
Name: ill it/try/27414 Date: - 6 / /
Address:'"!T ! A -/te/t/ cos ?Ai Ale �- / / Company Branch: /�/
City: 's- 4 a. - Act— State: ! ZIPC/y C7 Call Taken By:
Telephone(Wo : (Home): •
Disclaimer.This inspection covers gas distribution system equipment visible and readily accessible to the service technician
and represents the conditions existing on the date of inspectldnll98es not cover latent or manufacturing defects,the internal
workings of sealed equipment or/structural components;endrean7iotlbtconstrued to cover future or unforeseen happenings.
- ✓.-..,
Container Chedr r L 9 y
/l Size V I Serialft I Manufacturer
2ck l C) Lac uv &/ .L. x r6 C1v I r ST-
lla \ \ I _ -) , ^/yby
\ ' .J0. b L, , P U,�Y4/
Pressure Test Was a pressure test conducted? Yes 0 No ❑\ If yes,provide information below.
Test Stage Location Starting-Pressure(psi) \ Ending Pressure(psi) Start Time End Time ,
-.
1 \
sr, -/'i_ s
I \ i _s
System Leak Check , t I \
Test Stage Location Starting Pressure(psi or w.c.) + Ending Pressure(psi or w.c.) Start Time Eric Time
A'' cre�y Jawe_ jl /�D/iwc io_a5 G� 9,I
/0:3s
"`' �T�fe /D' C 1 . I0r' CJG /U,'V d /w /o .• SZ°;.,„
Regulator Check \
s Test Stage Location //f Vent Position(circle one) Flow r sure(psi or w.c.)� Lock Up
(psi or w.c.)
',i d s 7prP /l/� korrekt ) incorrect 77e � '/hp eS'r 1 �� , / it 6/� .
/ ev. incorrect
correct incorrect •tez" ,? ,
t. lc
Installation Review Yes No/ Yes No
Safety information and materials provided to customer 0 it Regulators)distance requirements-are met ,El 0
Container(s)distance requirements are met kJ' 0 Exterior-gas piping is suitable for continued service .el 0
Container(s)condition is suitable for continued service 12r 0 Dielectric isolation installed according to code a 0
Cathodic protection provided and documented p• ❑ for metallic pipe or-tubing(if applicable)
perc•mpan policy
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I, L/ tit , certify that I have completed the system check and installation review as described above.
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Se • t . r t""'m9 Nam
'se .,�J. ,,. . ure) .- t.f/ / Data /
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EGstomer Ackno -•gement I understand a system check and installation review has been completed on my gas system as described above.
I also acknowledge that the individual performing the Gas System Check informed me of the procedure and the outcome of the inspection;what was
covered by the inspection and what was not covered;what repairs and/or alterations,if any,were made to the gas system or appliances;and options
^pavailable for making recommended changes to my gas system.l further acknowledge,by initialing each of the foil owing items,that:
1„��\ I have informed the service technician of all gas-burning appliances and gas lines on my property.
l l\I 11 I have smelled the propane gas and can detect its odor. t\\
Ii\ft\\ I have been told what to do if I smell a gas odor or otherwise suspect a gas leak and have been shown how to turn the gas off at the container.
1;
I have been told that the odorant giving propane its distinctive smell can fade or diminish in intensity and that certain physical limitations
n((\ or conditions might prevent me from smelling a gas leak.
I" I have been told to consider installing one or more propane gas detectors listed by Underwriters Laboratories.
WI have received safety information and been told to read it and share it with all family members.
I am satisfied with these ice work performed.
have read// and fully understand this certification.
a Names In / l / / 1 .
, . timer _ •more) pate • .
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Repairs Completed: Recommended Actions(if applicable):
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. emends Pw,r Rearm6 Rtsruw CourCourts., PRC-009643
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