HomeMy WebLinkAbout5027 Northern Lights Dr - Special Inspections/Combustion Safety - 01/08/2014970-224-6134 11:37;05a.m. 09-28-2012 1/t
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. Community Development
C4, of 2a1 K College Ave.
art �ll�ns o Box 580
Fort Collins CO t10522
970.416.2740
970.224.6134 (fox)
fegov=WdeMopment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Falsting Rouses
Address: f-Q22ycx� r� \v� �c 1(,. cn X C Permit;#:� e.673
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012. _
Technician Name (print):Qi\t]cX ve-,,&r-7 CompanyZC.i \yv-,,\^ hycwkx.,,. s?1w. )
Technician Signatures Date
Appliance Tested: t.x lec (ro 4c�
Appliance Replaced: e. C
Worst Case Conditions:
Spillage Duration (in seconds Q_ Carbon Monoxide (parts per million): 9
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(wiled test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I certify that I am the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -ease conditions. I admowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST-.MJace nendnatuW-draJV4.25.12
Date