HomeMy WebLinkAbout1500 Buckeye St - Special Inspections/Combustion Safety - 06/25/2015� (r��� ltf
Community Development
�--- �l'}� 281 N. College Ave.
0) l 0l 11 S Fort Coll nPO Box 58s CO 80522
970.416.2740
970.2N.6134 (fax)
fcgov. corn/development
Combusdon Safety Test CompHance Form
Replacement of Na_ ,>ral DDIraft Appinances in Existing DDl®trses
Address: Permit#:
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: f
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): °Kr -
Pass )C Fail
Natfin>_ al Conditions.
Company rr: s (, �/s &'--
Date G/* lam
Carbon Monoxide .(parts per million):
):Date Tested:
Spillage Duration (in seconds): ; 7 Carbon Monoxide (parts per million): t
Pass iC Fail Date Tested: �—
(Failed rest regmh-es corrections un dl testpasses tender Nawral Condkions)
Technician's recernmendations to correct tested appliance failure:
P'2fled Worst Case Conditions:
I certify that I am the legal owner of the above listed property and hereby acknowledge that my appliance
has railed 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-dra8/4.25.12
Date