HomeMy WebLinkAbout404 Galaxy Way - Special Inspections/Field Verification - 05/18/2012Jul 20 12 04:53p Francisco Manzano 9705061GOS P.1
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: A .1 OLI kyja_�L V uw&/ Permit Nwnber-.
Approved Agency: I I
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
Vexation S. Fcbn=y 2012.
Technician Name (print): j14AQf7fW0 Company ri.CNCO RO(WRIIAL'tT?
Technician Signature: Date I<Z 112
Appliance Tested:
Appliance Replaced: PK
Worst Case Conditions:
Spillage Duration (in seconds): ;26 Carbon Monoxide (parts per million):
Pass v� Fail Date Tested: -5-
Natural Conditions:
Spillage Duration (in secondb)-. 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 property and hereby acknowledge that my appliance
has Wed a Combustion Safety Test under worst -case corldltiOns. I acknowledge that I have received a
combustion appliance safety information sheet,
Owner's Name (print)
Owner's Signature _
CST:reoaeomentinzknu-al-dmW4,25.12
Date