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Home My WebLink About820 Merganser Dr - Special Inspections/Combustion Safety - 04/05/2016 (2)-k�,dhns- 10 � Ill�rsw M k' n g 0 icyd r � ao `} r n n ,,Vat` son nr c�y c. .` 6c"1_y !^.:CJy .a�. u��XE6cParC d� •�C�•Gc��L©5 E.l.�J 6�i`ti ova nW< Community Development & Neighborhood Services 281 North College Avenue P.O. Box 580 Fort Collins, CO 80522.0580 970.416.2740 970.224.6134-fax fcgov. com Combustion Safety Test Compliance Form Replacement of Natural Draft Appliances in Existing Houses Address: 07,0 ► - ►gMa1Y/j&v- 17 0!;' Permit Number: D Z23 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 : 1 y (print) � � � �� _ Company S'�,s- v `r% Technician Signature: �j/� Date 5� Appliance Tested: ( ,LAkg —Yn ,4-r� Appliance Replaced: LtJa4c,4� Worst Case Conditions: Spillage Duration (in seconds : Carbon Monoxide (parts per million): Pass Fail Date Tested: Natural Conditions: Spillage Duration (iAi secon Carbon Monoxide (parts per million): Pass Fail Date Tested: S j (Failed test requires corrections until test passes under Natural Conditions.) i� I: 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