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Interruption of Service Form

  1. Completed Walk Through Visual Check (Check One)

  2. Tank

  3. Regulator

  4. Appliances

  5. Systems Leak Check

  6. Pressure Check

  7. DISCLAIMER

    This inspection covers LP-Gas (Propane) piping, fittings and equipment visible and accessible to Dealer's Representative and reflects the conditions existing on the date of the inspection. It does not cover latent or manufacturing defects, the internal workings of sealed equipment, structural components, or LP-Gas (Propane) products and cannot be construed to cover future defects ir unforseen happenings.

  8. Read and initial.

  9. By typing my name and date below, I hereby acknowledge that as the customer I am responsible for the system past the LP gas container service valve and throughout the building and that a pressure test and/or leak test has been performed and the system was found to be leak free.

  10. By typing my name and date below, I certify that a pressure and/or leak test has been performed and the system was found to be leak free.

  11. Leave This Blank:

  12. This field is not part of the form submission.