Form Mpgc 1027 PDF Details

The MPGC 1027 form serves as a critical tool for ensuring the safety of LP Gas systems within various institutions in Missouri. Mandated by the Missouri Propane Gas Commission, this form is an integral part of an annual inspection process that aims to prevent gas leaks and ensure systems are up to the standards of public safety. Key establishments such as schools, churches, nursing homes, and amusement parks are required to undergo these inspections by September 1 each calendar year, with summer camps and amusement parks having a deadline of June 1. The responsibility of securing an annual leak test falls on the shoulders of the institution’s owner or an appointed responsible person. This detailed form guides the inspector through checking the installations' compliance with not just the state regulations but also with the National Fire Protection Association's codes. It also involves assessing additions or removals of equipment, the safety of pilot systems, the condition of burners and venting systems, adequacy of combustion air, and the operation condition of the regulator. A failure to conduct this inspection not only puts the system at risk of being labeled unsafe but also holds legal implications. Upon completion, the form, which includes a declaration of the accuracy and completeness of the information provided, must be submitted to the Missouri Propane Gas Commission, fulfilling a vital step in prioritizing the safety and well-being of the public.

QuestionAnswer
Form NameForm Mpgc 1027
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesLeak Test Report 7 16 missouri propane form mpgc 1027

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MISSOURI PROPANE GAS COMMISSION

LP GAS INSPECTION AUTHORITY

4110 COUNTRY CLUB DR., STE. 200 JEFFERSON CITY, MISSOURI 65109-0302

LP GAS SYSTEM ANNUAL

LEAK TEST REPORT

NAME OF ORGANIZATION

MAILING ADDRESS

CITY/STATE/ZIP

LOCATION NUMBER

COUNTY

 

 

INSPECTION POINT

By the authority granted under 2 CSR 90-10.011 for the benefit of public safety, leak tests shall be made annually of all LP Gas systems at schools, churches, nursing homes, resorts, mobile home parks, public housing, hospitals, amusement parks, summer camps, (boy scout, girl scout, church, etc.) and other buildings and institutions. The tests shall be made on or before September 1 of each calendar year with exception of summer camps and amusement parks, which shall be completed on or before June 1 of each calendar year. It shall be the responsibility of the owner, administrator, superintendent, director, or other responsible person directly associated with any piping systems to assume full responsibility to secure the annual leak test of the LP Gas system. A registered installer or company shall perform all tests.

Failure to complete the annual leak test may be due cause to consider the LP Gas system unsafe for continued use and shall be reason to place the system out of service.

TYPE OF SYSTEM:

GENERATOR

VAPOR SERVICE

LIQUID SERVICE

VAPORIZER

SYSTEM PERFORMANCE INFORMATION

1.

Are tanks, piping, and appliances installed in compliance with NFPA 54, NFPA 58 and Missouri state regulations?

Yes

 

No

 

If no, explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Has any equipment been added or removed in the past twelve months?

Yes

 

 

No

If yes, list:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Are pilots/is pilot system safe?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Condition of burners:

Approved

 

 

Rejected

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Condition of venting systems/draft diverters:

 

 

Approved

 

 

Rejected

If rejected, explain:

 

 

 

 

 

 

 

 

 

 

6.

Is source of combustion air adequate?

Yes

No

If no, explain:

 

 

 

 

 

 

 

 

 

REGULATOR OPERATION/CONDITION

 

REGULATOR TYPE

 

 

 

REGULATOR MAKE

 

 

 

REGULATOR MODEL

 

 

REGULATOR DATE CODE

 

 

REGULATOR VENT CONDITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1ST STAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2ND STAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTEGRAL 2 STAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regulator lock up pressure:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are regulator vents protected?

Yes

No

If no, explain:

 

 

 

 

 

 

SYSTEM LEAK TEST

Method of leak test performed (See NFPA 54 Appendix D):

 

 

START PRESSURE

END PRESSURE

TIME HELD

SYSTEM OK

I hereby declare that all information submitted within this report is complete and accurate. (Submitting false or misleading information is a violation of Missouri State Law Chapter 575.060.)

SIGNATURE OF PERSON PERFORMING TEST AND INSPECTION

PRINT NAME

CONTACT PHONE NUMBER

DATE

 

 

 

 

NAME OF BUSINESS PERFORMING TEST AND INSPECTION

BUSINESS PHONE NUMBER

 

REGISTRATION NO.

 

 

 

 

SIGNATURE OF RESPONSIBLE PERSON FOR INSTITUTION OR SYSTEM

PRINT NAME

CONTACT PHONE NUMBER

DATE

 

 

 

 

Upon completion, make a copy for your records. Mail the original within five days to: Missouri Propane Gas Commission, 4110 Country Club Dr., Ste. 200,

Jefferson City, MO 65109-0302, or fax it to: (573)893-1074.

MPGC-1027 (04-10)

Page 1 of 1

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