HomeMy WebLinkAbout619 W Oak St - Special Inspections/Combustion Safety - 03/19/2015�; ®� Community Development
Fort Collins PO College Ave.
PO Boo x 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing houses
Address: 619 Gil QA-k S'T Permit #: 91�112ys
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):
Technician Signature:
Appliance Tested:
Appliance Replaced:
Company��'�
Date
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): ®/
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million)
Pass le 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 failed 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
CST:replacement/natural-draft/4.25.12
Date