HomeMy WebLinkAbout2218 Mathews St - Special Inspections/Combustion Safety - 04/11/2016Apr 11 1612:27p Hahn plumbing 970-493-5325 p.3
Planning, Development & Transportation Services
Community Development & Neighborhood Services
aty of 281 North College Avenue
P.O. Box 580
Fori Collins, CO 80522.0580
, ,r- ..... _ . 970.416.270-0
970224.6134- fax
fegov.com
Combustion. Safety Test Cons pliance Foam
Y.eplacem.eet of Natural Draft Appliances in It xistimg Houses
Address: l �``c��'���L' Permit Number-' )����
Approved Agency. -
Technician Name (print):
Technician Signature:�--- , �. �.1L '� �L1;'„ Date _ ti t L I iI^
5
Appliance Tested --
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in 'seconds): �Carbon Monoxide (parts per million): (r,
Pass Fail Date Tested: ` fl
(Failed test rep
ulres o ne.=''s signaikre acl:noWedging re silts ).
Natarral Conditions:
Spillage'Duration (in seconds):Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections u.'2til tesi plisses under l irm-r al Condi ors.)
Technician's reco endations to correct tested appliance failure:
c? C- [A 23 'vvL — b VtiF ',.tom r
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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 ackowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature J 1n _ _ Date t-i L Z ► �-'