HomeMy WebLinkAbout2454 Leghorn Dr - Special Inspections/Combustion Safety - 02/05/2014Planning, Development & Transportation Services
dommunIty Development & Neighborhood Services
City.
1
Ort Collins North 680 college Avenue
P.O.P.
P.O. Box 580
Fort Collins, CO 80522.0880
970.416.2740
970.224.6134-fax
fcgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: _, u ,5 `'t h V n Permit Number.
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Vern on 5, February 2012. ,/
Technician Name (print): 2 . U I N 4 Company �� rc�� `� a- /f r
Technician Signature:
Appliance Tested:j o,
Appliance Replaced:_
Worst Case Conditions:
Spillage Duration (in seconds): (D Carbon Monoxide (parts per million): 17
Pass Fail Date Tested: JY
Natural Conditions:
Spillage Duration (m seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed 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 properly and hereby acknowledge that my appliance
has famed a Combustion Safety Test under worst -case conditions. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CSTaeplacement/natural-draiV4.25.12
Date