HomeMy WebLinkAboutPROPANE SAFETY INSPECTIONOIL COMPANY 01 FLORIDA
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Account# -i t' 1 h'A — Name
State zip 34 Sq S. Phone
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R•OPANE SAFETY INSPECTION For new appliance Ea COMPLIANCE
installations record j RISK MANAGEMENT.
EW EQUIPMENT INSTALLATION only affectedequipment" t SAFETY -
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9 b 0 Date of Inspection d �:!. Branch/Location nQ ^.
Equipment•Type
Q-0 OV,:�"0P
E = Existing R
;;Removed I =.Installed
❑ E ❑ R j] r
❑ E ❑ R ❑
1 ❑ E ❑ R ❑ I
❑ E ❑ R ❑ I
❑ E ❑ R ' ❑ I
❑ E ❑ R ❑ I
Manufacturer
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Year Manufactured
,miEn
Model#
Serial#
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og
49
yFuel
BTUs (Maximum)nput)
®
DFER
Manual Shutoff
Ive
Sediment Trap
Burner(s) Condit!
n
. 0
Combustion Chai
iberCondition
00
Control/Pilot SafetySystem
2 C-
Venting System
'1
O
Combustion Air
4
CD
Taken Out of Svc.
orOperation (Tag #)
E
R
I.
Serial #
I ASME/DOT
ContainerT a
Size TankQ/o
Manufacturerg
Mfr.
Date 'Type
Re -qualification oatd
(DOT CylindersOniy)
Container
Relief
Valve
fittin s
Leakfheck
AG/UG/AGUG
Found,
I",
Cond.
Cond:
Date
Ca
•.
J.
System Type
D�tegral®
ostage❑Three stage ❑Integral&Two
Stage ❑ Integral &Three
Stage JurisdictionalAcct,
❑Y®11❑Unknown
Uncapped Gas Line
❑Yr.-10e-capped
Gas Line
I ❑Y❑N26A
°
Material �
Size .
Protection
�
E°
.R,
I
Mfr. �
Model#'�
Date Code
Cond.
dent Position
How Protected
- Integral
= Integral
11 Sta e
11 Stage
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) �
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2�d Sta e
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2hd Sta a
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3 d Stage
3`d Sta e
r
_Stage
_Stage
ja
Banded
0 E] No ❑Unknown Comment'
System Type
System Leak Check ®jfntireSystem
Pressure Test
System Operation Tests
Inwaltstai Pressure
End Pressure
Start Time
End Time Start
Pressure
End Pressure Start
Time
End Time
Flow Pressure Test
Lock -Up Pressure Test
Integral
1 st Stage
i
❑WC
ton. r� PSI
❑WC
L>YPSI
PSI
PSI
❑WC
❑ PSI
❑WC
? ❑ PSI
2nd Stage
❑WC
❑ PSI
❑wC
❑ PSI
PSI,PSI
❑wC
❑ PSI
❑WC
i ❑ PSI
3rd5tage
'
El WC
❑ P51-
❑ WC
❑PSI
PSI
PSI
wC
WC
Comments
I ( (❑ Property Owner ❑ Tenant); In addition; I have been told that certain physical limitations or conditions might prevent me from
acknowledge that the individual performing the propane safety review informed me of the procedure smelling a gas leak.
and the outcome of the review; what was covered by the review and what was not covered; what repairs • I have received customer safety information.and been told to read it and share it with all family. -
and/or alterations, H any, were made to the gas system or appliances, and options available for making members.
recommended char' es to my gas system. I further acknowledge, that: • I am satisfied with the service work performed.
' • I have informed tq individual performing the propane safety review of all gas burning appliances and • I have been told to consider installing one or more propane gas detectors listed by Underwriters,
,gas lines onmy property. Laboratories as an additional measure of security.
• I havebeen told w at to do if I smell a gas odor or otherwise suspect a,gas leak and have been shown I have been provided the following additional safety materials:
how to turn the ga offat the tank. ❑ Propane Safety Booklet{PRC-005606)
• I have smelled the ropane gas and can detect its odor. ❑ Important Propane Safety Information for You and Your Family Brochum(PRC-003121)
•,I have been told th itthe odorant giving propane its distinctive smell can fade or diminish in intensity. ❑ Carbon Monoxide Brochure (PRC-000075)
CIO, 9 (Z
Como Oil & Propane Re resentative Name - Print Customer Name -Print
Como Oil & Propane Representative Signature Date : :Customer Signature Date,
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