HomeMy WebLinkAbout2130 Eastwood Dr - Special Inspections/Combustion Safety - 06/27/2014FROM :NCR
FAX NO. :9702299983 1 Aug. 12 2014 03:39PM P1/1
City, of
rt Collins
Planning, Development & Transportation Services
291 iroaN �'�p � a bld0WM►h"d smvba6
P.O. Box 690
Fort OdIns. CO 80622.0690
910.419.1940
910.224.004- tak
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Combustion Safety Test Compliance Form
RWacemcnt of Natural Draft Appliances in Existing Houses
Address:._, a��!�! �Ul% ,�"C`� DIr . Permit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Teat in accordance with tort Collins Combustion Safety Teat Guide
- Version 5, February 2012.
Technician Name (print):. _ „�nc-alk, Company !t/
Technician Signature: ---.. ......__......... Date .. 2 i %y .
Appliance Tested: �J _
Appliance Replaced: k/z /y ---
Worst Case Conditions:
Spillage Duration (in seconds): 30 Carbon Monoxide (parts per million): 0
/
Pass Fail Date Tested: �_-Z % / y
Natural Conditions:
Spillage Duration (in seconds): 3 0 Carbon Monoxide (parts per million): 0
Pass If
S., 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 thatt Tam the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. I acknowledge that I have received a
comhwtion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:replacement/natumi•draft/4.25.12
Date