HomeMy WebLinkAbout1713 Valley Forge Ave - Special Inspections/Combustion Safety - 05/23/2013City of
Fort Collins
Planning, Development & Transportation Services
community Development & Neighborhood Services
201 North College Avenue
P.O. Box 600
Fort Collins, Co UOU22.0e00
970.410,2740
970.224.0134-fax
rcgov.cont
Combustion Safety Test Cotuhliauce Fornx
Replacement of Natural Draft Appliances In Existing Houses
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Address: J7�� VaLLe„� �--t,^u�,,.. 1'crmitNuruber: _
Approved Agency:
Technician Narno (print):
Technician Signature: _
Appliance Tested: UATE9- WP6_6 eK
A,ppliancc Replaced:
Worst Case Conditions:
Spillage Duration (in seconds)
Pass bail
Company QF- owl( �PAT`!1q �E Ai�
Date 5 -23 -13
Carbon Monoxide (parts per million):
Date Tuted:
(ailed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds): 3 Carbon Monoxide (parts per million):
Pass 'Fail Date Tested:
(Tailed test rewires corrections « ritil test passes « Wrist' Natural Cottrlitious.)
Technician's recommendations to correct tested appliance failure:
I certify that I am the legal owner ol'tile above listed property and hereby acknowledge that my
appliance has failed a Combustion Satety'f'cst under worst -case eolulitions. I acknowledge that
I have received a combustion appliance safety iml.'ormation sheet.
X Owner's Name (pri
X Owner's Signature