HomeMy WebLinkAbout2626 Bianco Dr - Special Inspections/Combustion Safety - 12/04/2015d Community Development
Oty� OR 281 N. College Ave.
F6rt FPO
oBox 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/devefopment
Combustion Safety Test Compliance ]Form
Replacement of Natural Draft Appliances in Existing Houses
Address: _% 0 � a 2) C ,V, ("o 1)r-I Permit r:
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safcty Test Guidc Vcrsion 5, February2012.
Technician Namc (print):
Technician Signature:
Appliance Tested:
Appliance Replaced: LLYCL+ed-
Worst Case Conditions:
v
Company G zgtt,dr
Date
Spillage Duration (in seconds): l y Carbon Monoxide (parts per million):
Pass j Fail Date Tested:
Natural Conditions -
Spillage Duration (in seconds):
Pass Fail
�— 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:
➢+ailed Worst Case Conditions:
.l 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) _
Owncr's Signature
CST: rep lacement/natural-draft/4.25.12
Date