Location of:

Type:

Manufacturer:

Model:

Serial Number:

Owned by Landlord/Homeowner:

Yes No

Inspected:

Yes No

Type of fuel:

Operating pressure in mbar and/or heat input kW/h or Btu/h:

Operation of safety device(s):

Pass Fail NA

Ventilation satisfactory:

Yes No

Visual Condition of fuel and termination:

Pass Fail NA

Fuel operation checks:

Pass Fail NA

Combustion analyser Reading:

Appliance serviced:

Yes No

CO Alarm fitted:

Yes No

CO Alarm tested:

Pass Fail NA

SAFE TO USE:

Yes No

GIUSP classification:

Warning/Advisory record (Insert from serial No):

Outcome of gas installation pipework visual inspection?

Pass Fail NA

Outcome of gas supply pipework visual inspection?

Pass Fail NA

Is the Emergency Control Valve access satisfactory?

Pass Fail

Outcome of gas tightness test?

Pass Fail NA

Is the Protective Equipotential bondind satisfactory?

Pass Fail