HomeMy WebLinkAbout3105 Swallow Pl - Special Inspections/Combustion Safety - 04/19/2014 (2)OCT/23/2014/THU 09:57 AM DELTA MECHANICAL —AZ
FAX No, 480-898-0005 P. 002
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Technician Name (pi
Technician Signature
Appliance Tested: _
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass Fail
Natural Conditions:
Planning, Development & Transportation Services
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291 North College Avenug
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970.418.2140
970.224.8134- tax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Permit Number: 61go col
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
Version S. February 2012.
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Date
Company
Carbon Monoxide (parts per million):
Date Tested: Si 19 14
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested: q
(Failed test requires corrections until test passes Wider ,Yaturtal Conditions.)
Technician's recommendations to correct tested appliance failure:
Failed ' Forst Case Conditions:
I certifv that I am the legal owner of the above listed property and hereby acknowicd-ee that my appliance
has failed a Combustion Safety Test under worst -case conditions. I acknowledge that I have received a
combustion applianec•satety information sheet.
Owner's Marne (print)
Owner's Signature
CST: rdplaccmant naairal-draft'4.215.12
Date