Gas Leak/Carbon Monoxide Investigation Report

CO Investigation Information

1. Are any members of the household feeling ill? Yes / No (if yes, advise customer to seek medical attention!)
2. Reason for investigation:

Customer Call:

Fire Department referral:

Other:

3. What appliances were in use in the last 24 hours?

Furnace: [ ]
Boiler: [ ]
Water Heater: [ ]
Range: [ ]
Dryer: [ ]
Fireplace: [ ]
Space Heater: [ ]
Kerosene Heater: [ ]
Wood Stove: [ ]
Vent Fan(s): [ ]
Other (list): _______________________________________________________

CO/Gas Leak Investigation

4. The gas leak/CO source was: Located? Repaired? (Circle all that apply)
5. Was a red tag hung during this call? Yes / No

CO/Gas Leak Investigation Checklist

Unsafe Condition Notice
( ) On the date and time listed above, a service representative observed your equipment at the above listed address to be operating with the following unsafe condition: _____________________
In the interest of your safety, our serviceman has turned off the gas/electricity supplying this equipment. A red tag indicating the problem was also attached to the equipment. The equipment should not be used until the unsafe condition(s) has been properly corrected. Your signature below indicates that the serviceman has informed you of the unsafe condition and the necessity of having the repair(s) made before this equipment can be operated safely.