HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 12/29/2016Planning, Development d Transportation Services
Community Development & Neighborhood services
F'or, t Coltins
281 North College Avenue
� ColsCO 80522 0560
970 416 2740 --�
970.224 6134- fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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Address �� i�%Q!2 a✓► Se✓�Q Permit Numbe�� l�
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the followmg
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
ersron ,Feb ary 2012
Technician Name (print) y Company <Q�yl1u,✓1!�] C /!y L'p'lrl�cV1
Technician Signature• Date / Z121i ///o
Appliance Tested �YA AX / �ct f co l� q/ol �tw l aQf-py-
Appliance Replaced t/ I r if n It i
Worst Case Conditions: 7
Spillage Duration (in seconds) Carbon Monoxide (parts per million)
Pass-4 Fail Date Tested:
Natural Conditions:
Spillage Durati9nia seconds)_ Carbon Monoxide (parts per million)
Pass Fail Date Tested:
(Failed test requires corrections until test passes under Natural Conditdons.)
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 admowledge that I have received a
combustion appliance safety information sheet
Owner's Name (print)
Owner's Signature _
CST neplacement/aat ual-draft/4 2512
Date