HomeMy WebLinkAbout1000 Province Rd - Special Inspections/Combustion Safety - 12/07/2015Fort
Cit ®f 281 N.Cite Development
Collins 281 ox58egeAve.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
kgov. com/de velopment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: i ; P12,611 � J r C Permit #:
K
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): . t ' , , i Company ill t
r
Technician Signature: Date ;Iz / S
Appliance Tested: ); i
Appliance Replaced.. ' -
Worst Case Conditions:
Spillage Duration (in seconds): �� Carbon Monoxide (parts per million): (,
Pass y, Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass ` Fail 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 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