DPH Gas-Fired Heating Form Edit 12 22 14 doc 3-1docx 2026

1. Click ‘Get Form’ to open the DPH Gas-Fired Heating Form in the editor.
2. Begin by entering the Facility Name and Address in the designated fields at the top of the form.
3. Select the Gas Type by checking either Liquid Propane or Natural Gas, ensuring you mark your choice clearly.
4. In the Equipment Approved section, indicate whether it is CSA, UL, or Other by filling in the appropriate box.
5. For Combustion and Make-Up Air, check 'Y' for Yes or 'N' for No based on your assessment of flame color and CO tester reading.
6. Proceed to Detection of Leaks and Venting sections, marking each item as applicable with 'Y' or 'N'.
7. Fill out the Location of Equipment section, indicating if it is under a window or in an enclosed area. Provide clearance from combustibles as satisfactory or unsatisfactory.
8. Complete the Protection section by entering details about who serviced the equipment, including name, licensed contractor number, company name, phone number, and date.

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