HomeMy WebLinkAbout2502 Owens Ave - Special Inspections/Combustion Safety - 05/11/2015Planning, Development & Transportation Services
Community Development a Neighborhood Services
� Col[�ns 2a1 No
rth College Avenue
F P.O. Box
580
oz 5a0
970
Collins,
Fort B0520580
970.416.2740 2
970.224.0134-fan
tcgovoom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses,
Address:. �� t/C10, Permit Number. I ✓` ' `"`��
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 5, February 2012.
Technician Name (print): Company IA .
Technician Sienaturot%//�� Date
Appliance Tested: _
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): �T Carbon Monoxide (parts per million):_
Pass Fail
Natural Conditions:
Spillage Duration (in seconds): _
Pass Fail
Date Tested:
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to convect 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•drafl/4.25.12
Date