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Gas Test Results
Customer Name
*
Site Address
*
Job Number
*
Description of gas fitting work
*
Category
*
Domestic
Commercial
Industrial
Temporary
Other
Type (Regulation 24(1))
*
New
Addition
Extension
Replacement
Alteration
Repair following accident
Other
Risk Classification
*
Low-risk
General
High-risk
Gas Type
*
Natural Gas
LPG
TLP
Bio
Appliances
Type
*
Brand
*
Model (e.g. Infinity or HO-1-6S-3GW)
*
Input Rate mj/hr
*
Flue Type & Location
Internal Flue
External Flue
Fan assisted Flue
N/A - No Flue
Vent Type & Location
Mechanical
Natural
Appliance Location
*
Pipework Installed (attach pipework diagram or photo)
*
Yes
No
Click to choose a file or drag here
Test Results
*
*
*
*
Other Testing
Combustion
Yes
No
Ventilation
Ventilation
Yes
No
Registration number(s) of anyone who carried out work
*
Gasfitter Signature
*
Signature
*
*
Submit
