HomeMy WebLinkAbout2503 Phantom Creek Ct - Special Inspections/Combustion Safety - 05/31/2016 (2)Fort Cothns
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
Icgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:,Permit Number:
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, F bruary 2012-
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Technician Name (prinCompany a G✓t
Technician Signature: Date
Appliance Tested: if ff -
Appliance Replaced:
Worst Case Conditions: _�
Spillage Duration (in seconds): I� Carbon Monoxide (parts per million):
Pass 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 Date
CST: replacement/natural-draW4.25.12