HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 04/27/2017--�Li.IZQ. 1�w►0-
�yA r Community Development
Fortyt_ Collins Po Box 580geAve
Fort Collins, CO 80M
970.416.2740
970 224 6134 (fax)
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 0,
Permit #. .2'1I S�
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012
Technician,Na=(print):<fA Company 46/&-,, n y--ew
Technician Signature. Date ? /
Appliance Tested. /W wo. C4
Appltance Replaced: I ! ( l / t /
Worst Case Conditions:
Spillage Duration (in seconds). �/ Carbon Monoxide (parts per million):
Pass /� Fail Date Tested: TA/%
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/natural-draft/4.25 12
Date