10249_0001 (3).tif 71 LP Gas Consumer Installation Record �, }
Name 0Q Installation /Inspection Date -"
Street `� 1 ity State 1 Phone
Furnace Kitchen Range Water Heater Clothes Dryer
Manufacturer
Serial /Model Number
BTU Rating
System or equipment "Red Tagged" due to condition or because subject to recall? .. ............................... ❑ Yes
If yes, explain /identify
Is each vented type of appliance vented to the outside air? ........................................ ............................... des ❑ No
Any unvented space heaters installed in bedrooms? ..................... ............................... ..................... ❑ Yes Cd.Ne
If yes, is each such heater equipped with an oxygen depletion safety shutoff system? ....................... El Yes ❑ No
Size of tanks) -`_
Tank(s) located I feet from closest building.
Tank(s) mounted on substantial, non - combustible base? ........................................... ............................... fames ❑ No
Any sources of ignition within 10 feet (5 feet for cylinders in exchange service)? ....... ............................... ❑ Yes 11
i
Starting Pressure Ending Pressure Time Held (Minutes) Leak Free? (Yes or No)
Leak Check I `- " I t�_> Z
Service Line is: Iron Pipe Copper Tubing Plastic Other
Piping or tubing is buried and /or protected from damage
Does the service line enter the structure above ground? .............. ............................... .......................11.1.1. lees ❑ No
If no, is it sealed or installed in gas tight conduits ............ . ...................... . ❑ Yes ❑moo
Any unused gas piping outlets indoors? ......... ............................... .. ...................... ............................... El Yes
If yes, is each unused gas piping outlet fitted with a gas tight threaded plug or cap? ........................... ❑ Yes ❑ No
Single Stage or First Stage Regulator Date Code �jr �'� Second Stage Regulator Date Code
All regulators located outdoors are installed or protected so operation will not be affected
by the elements (for example, freezing rain, sleet, snow, ice, mud, or debris)? ..... ............................... Ces ❑ No
All regulators properly secured? .....I ............................... .......... I ......................................................... Ct e El No
Second stage regulator located outdoors? ............................ ..................................... ................I.............. es ❑ No
If not, is the vent outlet piped out of doors? ............................. ............................... .1. ❑ Yes ❑ No
Is -s-regulatorvent discharge Iodated at least 3 feet horizontally away`from any building opening
below the level of the discharge? ............... ............................... .. .................... ....1...1.1..................1 s ❑ No
By signing I, (Customer's Name) acknowledge:
1 understand how to turn off my supply of gas in case of emergency.
® 1 have smelled propane and can detect its odor.
• 1 have received consumer safety information and an odor sniff sample.
• 1 have been advised to install a combustible gas detector.
® Any deficiencies and /or corrections necessary have been clearly explained to me.
Customer Sign Date
Service Technician Sign Date
This inspection is expressly limited to LP gas piping and equipment visible and accessible to the service technician and
reflects the conditions existing at the time of the inspection.
I
When additional supply of this form is needed, write Federated Insurance Companies, 121 East Park Square,
Owatonna, MN 55060, or call: 1- 800 - 838 -1760. Copies are provided free of charge to Federated policyholders.
F70-184sET Ed. 9 -12 Customer Copy