Jemena Asset Management Pty Ltd ABN 53 086 013 461

Leak Test Certificate Form Jemena Asset Management Pty Ltd ABN 53 086 013 461

Serial No.

Property Details

Licensee’s Details

Installation Details

Test Results

In respect to the gasfitting work, I certify that:

1. The gasfitting work complies with the Jemena Network Operator Rules; 2. I have tested the installation for defects immediately after completion and inspected all piping and appliances connected to the

installation, where the gasfitting work was undertaken by me; and 3. The installation is in safe working order

Name: Signature:

Street Suburb Postcode House/Unit No.

Lot No. DP No. Nearest Cross Street

Owner’s Name Owner’s Name Postal Address

Name Postal Address

Licence No.

Phone Number Supervisor Licence No.

Expiry Date

Expiry Date

Leak Test Date

DD MM YYYY

DD MM YYYY

DD MM YYYY

Installation Type

Domestic

I&C

Type of Work

Meter No.

New

Alteration

Extension

Repair (details)

Consumer Service Details

Service Material

Service Size

Safe

Unsafe

Gas Installation tested and is safe to connect; i.e. gas supply has been ready, or is ready, to be established or re-established

Gas Installation is defective and unsafe to connect. NOTE: If this box is ticked, please provide details below

Details of Faults Identified

DD MM YYYY

Jemena’s Copy

Revision Date: 18/12/2019

Jemena Asset Management Pty Ltd ABN 53 086 013 461

Leak Test Certificate Form Jemena Asset Management Pty Ltd ABN 53 086 013 461

Serial No.

Property Details

Licensee’s Details

Installation Details

Test Results

In respect to the gasfitting work, I certify that:

1. The gasfitting work complies with the Jemena Network Operator Rules; 2. I have tested the installation for defects immediately after completion and inspected all piping and appliances connected to the

installation, where the gasfitting work was undertaken by me; and 3. The installation is in safe working order

Name: Signature:

Street Suburb Postcode House/Unit No.

Lot No. DP No. Nearest Cross Street

Owner’s Name Owner’s Name Postal Address

Name Postal Address

Licence No.

Phone Number Supervisor Licence No.

Expiry Date

Expiry Date

Leak Test Date

DD MM YYYY

DD MM YYYY

DD MM YYYY

Installation Type

Domestic

I&C

Type of Work

Meter No.

New

Alteration

Extension

Repair (details)

Consumer Service Details

Service Material

Service Size

Safe

Unsafe

Gas Installation tested and is safe to connect; i.e. gas supply has been ready, or is ready, to be established or re-established

Gas Installation is defective and unsafe to connect. NOTE: If this box is ticked, please provide details below

Details of Faults Identified

DD MM YYYY

Licensee’s Copy

Revision Date: 18/12/2019

Jemena Asset Management Pty Ltd ABN 53 086 013 461

Leak Test Certificate Form Jemena Asset Management Pty Ltd ABN 53 086 013 461

Serial No.

Property Details

Licensee’s Details

Installation Details

Test Results

In respect to the gasfitting work, I certify that:

1. The gasfitting work complies with the Jemena Network Operator Rules; 2. I have tested the installation for defects immediately after completion and inspected all piping and appliances connected to the

installation, where the gasfitting work was undertaken by me; and 3. The installation is in safe working order

Name: Signature:

Street Suburb Postcode House/Unit No.

Lot No. DP No. Nearest Cross Street

Owner’s Name Owner’s Name Postal Address

Name Postal Address

Licence No.

Phone Number Supervisor Licence No.

Expiry Date

Expiry Date

Leak Test Date

DD MM YYYY

DD MM YYYY

DD MM YYYY

Installation Type

Domestic

I&C

Type of Work

Meter No.

New

Alteration

Extension

Repair (details)

Consumer Service Details

Service Material

Service Size

Safe

Unsafe

Gas Installation tested and is safe to connect; i.e. gas supply has been ready, or is ready, to be established or re-established

Gas Installation is defective and unsafe to connect. NOTE: If this box is ticked, please provide details below

Details of Faults Identified

DD MM YYYY

Owner’s Copy

Revision Date: 18/12/2019