HomeMy WebLinkAbout1609 Shenandoah Cir - Special Inspections/Combustion Safety - 07/14/2015Fort Collins
Planning, Development & Transportation Services
Community Dovelopmont & Neighborhood Service*
281 North College Avenue
P.O. Box 680
Fort Collins, CO 60522.0580
970.416.2740
970.224.8134• fax
fcgov.com
Combustion Safety Test Compliance Form
/Replacement of Natural Draft Appliances in Existing Houses ✓
Address: )/0I9�1 She�ak- Permit Number: JV
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):
Technician Signature:
Appliance Tested: _
Appliance Replaced: _
A )Gig -
Date ±-iq!=
Worst Case Conditions:
Spillage Duration (in seconds): eRl Carbon Monoxide (parts per million):
Pass __,,-"F aiI Date Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes tinder 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