THIS FORM IS FOR TRAINING PURPOSES ONLY - IT IS NOT A VALID SAFETY CERTIFICATE
My Name
First Name
Last Name
Centre/College Details
Supervising Engineer Details
Name
Gas Licence
Gas Registration
Date
-
Day
-
Month
Year
Date
Inspection Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
The Following Part of the Gas Installation Has Found to be Unsafe
Gas Appliance
Gas Pipework
Gas Meter / ECV
Type option 4
Other
Details of Unsafe Situation(s)
Category of Unsafe Situation (s)
ID Immediately Dangerous Installation
ID Immediately Dangerous Appliance(s)
AR AT Risk Installation
AR AT Risk Appliance(s)
IR Immediately Reportable to the Gas Transporter
Other
The Installation / Appliance(s) Have been Made Safe as Follows
Gas Appliance(s) Disconnected From the Gas Supply and a Warning Label Attached
Gas Appliance(s) Turned Off and Warning Label Attached
Gas Supply Capped / Isolated / Meter Disc and a Warning Label Left
Gas Supply Turned Off at the ECV and The Transporter Notified
The Customer / Gas User has refused permission to make safe the gas fitting and as such this has been reported to the Gas Transporter / ESP
Where the unsafe situation has been reported to the Gas Transporter / Emergency Service Provider please enter the reference number below
The Dangerous Situation Identified Must be rectified by a competent, qualified person who is a member of the competent persons scheme. Reconnecting or using an appliance which has been found to be dangerous is an offence and can lead to prosecution.
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