HomeMy WebLinkAbout1307 Fairway Five Dr - Special Inspections/Combustion Safety - 12/17/201301-16-14;02:41PM; ;970-484-4448 # 1/ 1
Manning, Development & Transportation Services
CityOf i Co:nmur4ty Qevetopment a Holghtsor.400d 3arAcoo
�°201 N*M Co fte Maim
P.O. OUR 580
Fort COMM. CO 80522.0580
070.416.2740
f 970.224.0134• tax
' fcywr.rom
Combustion S ale ylest Compliance Form
Respaaeement o IVatnaral >�sfft Pat��f4 aitmces iai'�s3stii�g IHCoaasea
Address: PermitNumbm: �I 3G(rCo52.
Approved Agency:
Technician Name (print,)::7�
Technician Signature:
Appliance Tested: W/— 7 I
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass l;
('railed test red
Natu>rai Coendiflons:
Spillage Duration (in seconds):
Pass 1
( Failed test requires
If
Company/��r� _se.�(/l6
Date /al
JS c,
Carbon Monoxide (parrs per million): - Ze,_
ilDate Tested:
owner's signod ure acinowledgiung resufr:..)
Carbon Monoxide (parts per million):
Date Tested;
until Best paves under Natural Conditions.)
Technician's recommendatibns io correct tested appliance failure:
1 certify (hat I am the legal own' of the above Ikated property and hereby acknoAdge that 'my
appliance has failed a Combusti n Safety Tf e,under worst -cave comdiflous..l aicknowledge that
1 have received a combustion a fiance safety information, sheet.
Owner's Name (F
Owner's Signatur