HomeMy WebLinkAbout1407 Sanford Dr - Special Inspections/Combustion Safety - 02/27/2014i
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Manning, Development & Transportation Services
ec;nmunity Govelopme nt a Nolghtro ,ecd Sor Acoa
281 RNarth College Mama.:
P.O. Box Sao
Fort Collim, CO a0522.05a0
970.413.2740
970.224.6134-tax
lcgov. cam
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Combustion Safety Test CaDmpRiance Forrnt
Replacement of Natural Draft Appagances lea IESdstang Houses
Address: t!D ��� Permit Number: B /L/O1.) y
,approved Agency:
Technician Name
Technician S
.Company
Date
Appliance Tested:
IL
Appliance Replaced:�o-
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I.
Worst Cause Conditions: l
Spillage Duration (in seco ds): — Carbon Monoxide (parts per million):
Pass l� Fail Date Tested:
(Failed test req +lrea owners signature acADaowledgaDag resuleo.)
Natural Conditions:
i
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(A aided test requires c Prrections until test passes under Natural Conditions.)
Technician's recommendations jo correct tested appliance failure:
1 certify that I am the legal own r of the above li,5ted property and hereby acknoAdge that my
appliance has failed a Combustion Safety Test'mder worst -ease condtfloms..l acknowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature _ Date