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HomeMy WebLinkAbout3219 Silverwood Dr - Special Inspections/Combustion Safety - 06/13/2016tie ;off::: p ;3~ ': :. s a aiisportation Services 8 yo,�� t:* o nor .,zloty L�.1 � s�; ::ers : a Neighborhood Services 281 North College & enue P.O. Box F�+^ ort Collins Fort Colli s80 ; CO 80522.0580 ! 970.416.2740 970.224.6134-fax fcgovcom Combustion Safety Test Compliance Form Replacement of Natural Draft Appliances in Existing H1,D606 uses Address: ! ~I 51 �(/� t`✓a©(� Permit Number: , 6 0 6 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 Version5, February 2012. Technician Name (print): l►, �, Company Technician Signature: _/ Date ' Appliance Tested: Appliance Replaced: Worst Case Conditions: Spillage Duration (in seconds): � 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 CST:replacement/natur-9-draftf425.12 Date