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Gas Piping Pressure and Leakage Test Form

Test Requirements & Notes:

Test duration: A minimum of two (2) readings shall be taken not less than 30 minutes apart.
Pressure levels: Test pressures shall be in accordance with the Fuel Gas Code of New York State. The test pressure to be used shall be no less than 1-½ times the proposed maximum working pressure, but no less than 3 psig (20 kPa gauge), irrespective of design pressure.
This is not a meter order: Submitting this form does not constitute a meter order.
Validation duration: The results of this test shall be deemed valid for a period of two (2) years from the date of the test barring any changes to the piping system.
Inspection & re-inspection fees: In activating the service, an initial inspection by Central Hudson personnel will be done at no charge. If the piping system fails to meet our requirements, a fee may be applied for each subsequent re-inspection conducted, with payment to be made prior to the re-inspection.

Complete and submit the form below or this downloadable PDF version.

Customer Account Number:

Job #:

Name of Professional Certifying These Test Results:

Certification statement I certify that I am the professional listed above and I have tested the gas piping system at the address specified below, the results of which are entered below.

Customer Address:

Street Address:

City/Town:

Zip Code:

Pipe Installed

Diameter Size 1:

Length of Diameter Size 1:

Diameter of Size 2:

Length of Diameter Size 2:

Test Results

Test duration is required to be 60 minutes at minimum

Start of Test Date:

Start of Test Time:

Start of Test Gauge Pressure:

Read By:

1st Reading Date:

1st Reading Time:

1st Reading Gauge Pressure:

Read By:

2nd Reading Date:

2nd Reading Time:

2nd Reading Gauge Pressure:

Read By:

I further certify that the piping described above is free of any leaks, in accordance with Central Hudson's "Specifications and Requirements for Gas Installations", and adequate to serve gas to the appliances installed at the above-mentioned location.

Testing Company Information:

Company Name:

Phone Number:

Email Address:

Type Your Name to Sign:

Today's Date:

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Gas Piping Pressure and Leakage Test Form

Test Requirements & Notes:

Customer Address:

Pipe Installed

Test Results

Testing Company Information: