HomeMy WebLinkAbout2830 Blue Leaf Dr - Special Inspections/Combustion Safety - 03/17/2016Clty, of
Fort coilins
Planning, Development & Transportation Services
Community Development 6. Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
ropov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses yy��
Address: 2830 BLUE LEAF DR FC Permit Number:&ub�HSD
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): BOBBY KOHN Company NORTHERN COLORADO AIR, INC
Technician Signature:' Date
Appliance Tested;
WATER HEATER
Appliance Replaced: FURNAC,F —
Worst Case Conditions. -
Spillage Duration (in seconds Carbon Monoxide (parts per million):
Pass Fail Date Tested: `'/6
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail _ Date Tested:
(Failed test requires corrections until test passes trader 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:repl acement/natural-draft/4.25.12
Date