HomeMy WebLinkAbout5030 Sawhill Dr - Special Inspections/Combustion Safety - 02/25/2015Planning, Development & Transportation Services
City O� Community Development s Neighborhood Services
281 North College Avenue
` Collins FP.O. Box 580
ort rt (f Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
fcgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: SO a �" Permit Number: 5 I
Approved Agency:
I hereby attest that 1 have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion afety Test Guide
I ( Version , February 2012. fj
Technician Name (print): /L F ��. Ct Company c-42t o- If �Ct1
�J/ " /w
Technician Signature:
Appliance Tested: _
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): _
Pass Fail
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Date 2— z5
y Carbon Monoxide (parts per million): CD
Date Tested:
Carbon Monoxide (parts per million):
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 1 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: rep I acement/n atural-draftl4.25.12
Date
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