Fillable Form 1: Gas Safety Checklist Gasfitter contact details (Department of Infrastructure, Transport, Cities and Regional Development)

Fill Online, Printable, Fillable, Blank Form 1: Gas Safety Checklist Gasfitter contact details (Department of Infrastructure, Transport, Cities and Regional Development) Form

Use Fill to complete blank online DEPARTMENT OF INFRASTRUCTURE, TRANSPORT, CITIES AND REGIONAL DEVELOPMENT pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: Gas Safety Checklist Gasfitter contact details (Department of Infrastructure, Transport, Cities and Regional Development)

On average this form takes 7 minutes to complete

The Form 1: Gas Safety Checklist Gasfitter contact details (Department of Infrastructure, Transport, Cities and Regional Development) form is 3 pages long and contains:

  • 0 signatures
  • 7 check-boxes
  • 25 other fields

Country of origin: AUSTRALIA
File type: PDF

Use our library of forms to quickly fill and sign your Department of Infrastructure, Transport, Cities and Regional Development forms online.

BROWSE DEPARTMENT OF INFRASTRUCTURE, TRANSPORT, CITIES AND REGIONAL DEVELOPMENT FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
29/03/2021
Gas Safety Checklist
Gas Safety Check
This inspection is for gas safety purposes only and is in accordance with the requirements of the Residential Tenancies Regulations 2021 and the
Residential Tenancies (Rooming House Standards) Regulations 2012
Gasfitter contact details
Safety check completed by: <<Business name>> Inspection date:
Name: <<Type A Appliance Servicing Gasfitter’s name>> Licence/ registration no.:
Business address: Telephone:
Note: It is an offence to perform Type A gas appliance servicing work without the required qualifications (refer to the Plumbing Regulations)
Property
Property type Rental property Rooming house
Property address Owner/ Rental provider/ Agent Name:
Address:
Telephone:
Authority to proceed
(Owner/Rental provider/Agent):
Print name:
By checking this box I acknowledge receipt
of this gas safety check and its result:
Date:
Record observations, including burner pressures, and faults in the observations table below)
Appliance 1
(location, type, make and model):
Installation check
Result
Is the installation gastight in accordance with AS/NZS5601.1?
Is the appliance and its components accessible for servicing and adjustment?
Where required by AS/NZS5601.1 is an isolation valve provided at the inlet connection of the appliance?
Is the appliance and its installation electrically safe? (Note: Electrical safety is confirmed by checking the electrical supply is isolated, checking earth continuity, checking insulation resistance
(where applicable) and using bonding straps if disconnecting an appliance)
Is there evidence of certification? (AGA, SAI -Global, IAPMO, Global-Mark or BSI). (Record in the observations table if there is no evidence of certification).
Where applicable are gas appliances including cookers adequately restrained from tipping over?
Is the room ventilation adequate for the installed appliances? (consider installation and building date for applicable requirements)
Where visible are clearances from combustible surfaces in accordance with the installation instructions and AS/NZS5601.1?
Where applicable is the cowl, chimney plate or flue terminal in good condition and clear of obstruction?
Where applicable is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at roof penetration?
Where applicable is the flue, or its surroundings, clear of signs of scorching or overheating?
Appliance servicing
(For guidance on servicing Type A gas appliances refer to AS4575):
Result
Where applicable is the heat exchanger in good condition (test for spillage of combustion products)
Has the appliance been cleaned of dust and debris (e.g. burner, pilot, fan, filters, air intake)?
Are gas supply and burner operating pressures correct? (Note: All appliances must be operating)
Is the appliance clean of dust and debris (e.g. burner, pilot, fan, filters, air intake)
Are burner flames normal? (i.e. no evidence of flame lifting, floating, yellow tipping or sooting)
Is the appliance operating correctly including safety devices such as pressure and temperature relief valves?
Appliance 2 (location, type, make and model):
Installation check
Result
Is the installation gastight in accordance with AS/NZS5601.1?
Is the appliance and its components accessible for servicing and adjustment?
Where required by AS/NZS5601.1 is an isolation valve provided at the inlet connection of the appliance?
Is the appliance and its installation electrically safe? (Note: Electrical safety is confirmed by checking the electrical supply is isolated, checking earth continuity, checking insulation resistance
(where applicable) and using bonding straps if disconnecting an appliance)
Is there evidence of certification? (AGA, SAI -Global, IAPMO, Global-Mark or BSI). (Record in the observations table if there is no evidence of certification).
Where applicable are gas appliances including cookers adequately restrained from tipping over?
Is the room ventilation adequate for the installed appliances? (consider installation and building date for applicable requirements)
Where visible are clearances from combustible surfaces in accordance with the installation instructions and AS/NZS5601.1?
Where applicable is the cowl, chimney plate or flue terminal in good condition and clear of obstruction?
Where applicable is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at roof penetration?
Where applicable is the flue, or its surroundings, clear of signs of scorching or overheating?
Add reference number, e.g. invoice number or job card number
2 29/03/2021
Appliance servicing (For guidance on servicing Type A gas appliances refer to AS4575):
Result
Where applicable is the heat exchanger in good condition (test for spillage of combustion products)
Has the appliance been cleaned of dust and debris (e.g. burner, pilot, fan, filters, air intake)?
Are gas supply and burner operating pressures correct? (Note: All appliances must be operating)
Is the appliance clean of dust and debris (e.g. burner, pilot, fan, filters, air intake)
Are burner flames normal? (i.e. no evidence of flame lifting, floating, yellow tipping or sooting)
Is the appliance operating correctly including safety devices such as pressure and temperature relief valves?
Appliance 3 (location, type, make and model):
Installation check
Result
Is the installation gastight in accordance with AS/NZS5601.1?
Is the appliance and its components accessible for servicing and adjustment?
Where required by AS/NZS5601.1 is an isolation valve provided at the inlet connection of the appliance?
Is the appliance and its installation electrically safe? (Note: Electrical safety is confirmed by checking the electrical supply is isolated, checking earth continuity, checking insulation resistance
(where applicable) and using bonding straps if disconnecting an appliance)
Is there evidence of certification? (AGA, SAI -Global, IAPMO, Global-Mark or BSI). (Record in the observations table if there is no evidence of certification).
Where applicable are gas appliances including cookers adequately restrained from tipping over?
Is the room ventilation adequate for the installed appliances? (consider installation and building date for applicable requirements)
Where visible are clearances from combustible surfaces in accordance with the installation instructions and AS/NZS5601.1?
Where applicable is the cowl, chimney plate or flue terminal in good condition and clear of obstruction?
Where applicable is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at roof penetration?
Where applicable is the flue, or its surroundings, clear of signs of scorching or overheating?
Appliance servicing
(For guidance on servicing Type A gas appliances refer to AS4575):
Result
Where applicable is the heat exchanger in good condition (test for spillage of combustion products)
Has the appliance been cleaned of dust and debris (e.g. burner, pilot, fan, filters, air intake)?
Are gas supply and burner operating pressures correct? (Note: All appliances must be operating)
Is the appliance clean of dust and debris (e.g. burner, pilot, fan, filters, air intake)
Are burner flames normal? (i.e. no evidence of flame lifting, floating, yellow tipping or sooting)
Is the appliance operating correctly including safety devices such as pressure and temperature relief valves?
Appliance 4
(location, type, make and model):
Installation check
Result
Is the installation gastight in accordance with AS/NZS5601.1?
Is the appliance and its components accessible for servicing and adjustment?
Where required by AS/NZS5601.1 is an isolation valve provided at the inlet connection of the appliance?
Is the appliance and its installation electrically safe? (Note: Electrical safety is confirmed by checking the electrical supply is isolated, checking earth continuity, checking insulation resistance
(where applicable) and using bonding straps if disconnecting an appliance)
Is there evidence of certification? (AGA, SAI -Global, IAPMO, Global-Mark or BSI). (Record in the observations table if there is no evidence of certification).
Where applicable are gas appliances including cookers adequately restrained from tipping over?
Is the room ventilation adequate for the installed appliances? (consider installation and building date for applicable requirements)
Where visible are clearances from combustible surfaces in accordance with the installation instructions and AS/NZS5601.1?
Where applicable is the cowl, chimney plate or flue terminal in good condition and clear of obstruction?
Where applicable is the flue adequately supported and correctly installed (i.e. terminal has correct clearance distance) and sealed at roof penetration?
Where applicable is the flue, or its surroundings, clear of signs of scorching or overheating?
Appliance servicing
(For guidance on servicing Type A gas appliances refer to AS4575):
Result
Where applicable is the heat exchanger in good condition (test for spillage of combustion products)
Has the appliance been cleaned of dust and debris (e.g. burner, pilot, fan, filters, air intake)?
Are gas supply and burner operating pressures correct? (Note: All appliances must be operating)
Is the appliance clean of dust and debris (e.g. burner, pilot, fan, filters, air intake)
Are burner flames normal? (i.e. no evidence of flame lifting, floating, yellow tipping or sooting)
Is the appliance operating correctly including safety devices such as pressure and temperature relief valves?
LP Gas cylinder and associated components (where applicable)
Result
Are cylinders installed on a firm, level and non-combustible base, and not resting on soil?
Are LP Gas cylinders suitably restrained and have compliant clearances?
Are hoses, pigtail and fittings in good condition and not degraded or work hardened?
Are pressure regulators correctly fitted, orientated, set and complete?
3 29/03/2021
Combustion spillage from open flued and room sealed appliances
(Refer to ESV Gas Information Sheet 38 and AS 4575)
B
efore proceeding with combustion product spillage testing ensure the appliance is clean and operating in accordance with the manufacturer’s requirements. Combustion products readings should
be recorded in the observations table
Appliance 1 (location, type, make and model):
Negative pressure test (open flued appliances only) - Was there a negative pressure?
Spillage test - Was there spillage of combustion products?
Appliance 2 (location, type, make and model):
Negative pressure test (open flued appliances only) - Was there a negative pressure?
Spillage test - Was there spillage of combustion products?
Appliance 3 (location, type, make and model):
Negative pressure test (open flued appliances only) - Was there a negative pressure?
Spillage test - Was there spillage of combustion products?
Dangerous gas installations
Gas Safety (Gas Installation) Regulations 2018, Part 3, Division 3, Section 21
1. If a person carrying out gasfitting work on a gas installation becomes aware of a danger arising from a defect in the gas installation, the person must without
delay—
a) take all steps that are necessary to make the installation safe; and
b) notify the owner of the gas installation and the occupier of the premises in which the installation is situated of the defect.
2. Sub regulation (1)(a) does not apply if the person is unable, or it is unreasonable for the person, to take the necessary steps to make the gas installation safe.
3. If the person carrying out the gasfitting work is unable, or it is unreasonable for the person, to make the gas installation safe, he or she must, without delay, notify
Energy Safe Victoria and—
a) if the gas installation uses natural gas, the gas distribution company which supplies that gas to the gas installation of the defect; or
b) if the gas installation uses LPG, the gas retailer which supplies that gas to the gas installation of the defect.
Observations and identification of faults
Details of observations and identified faults
Note: Include reference to a Compliance Certificate number if applicable
Remedial action to be taken
Declaration
I, being the person responsible for the inspection of the identified gas appliances or installations in the rental property or rooming house, particulars of which are described
here, having exercised reasonable skill and care when carrying out the inspection, hereby declare on the date of inspection that the information in this report, including the
observations and recommendations, provides an accurate assessment of the condition of the gas appliances or installations in the rental property or rooming house taking into
account the stated extent of the installation and the limitations of the inspection and testing.
I further declare that in my judgment, the said appliance(s) and corresponding installation(s) is/are:
Compliant – gas appliance or gas installation complies with the criteria for a “gas safety check” in the residential tenancies regulations
Non-compliant – no immediate risk, however the customer should be advised that remedial work is required to be carried out to bring the gas appliance or its
installation up to standard.
Unsafe– gas appliance or its installation is unsafe and requires disconnection and urgent work as the safety of persons may be at risk or there may be damage to
property
By checking this box the gasfitter acknowledges that he/she has completed this gas safety check:
Next gas safety check is due within 24 months. Next gas safety check due:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: Gas Safety Checklist Gasfitter contact details (Department of Infrastructure, Transport, Cities and Regional Development)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document