HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 04/17/2017�,� . O Community Development
_,� ortcottins 281 N. College Ave
Pb Box 580
Fort Collins, CO 80522
,' � 970.416.2740
970 224 6134 (tax)
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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Address: 4Q.240 l�iPfq�'J(�� Permit
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,Name(print): 'v--5 gszk Company �is�l�.� $e/d%cc [B. r,•,_�y
Technician Signature:
Appliance Tested: _
Appliance Replaced
It
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Worst Case Conditions:
Spillage Duration (in seconds Carbon Monoxide (parts per million):
Pass Fail Date Tested: t l
Natural Conditions:
Spillage Duration din seconds):
Pass —Z Fail
Carbon Monoxide (parts per million) %5
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 (pnnt)
Owner's Signature
CST replaceinent/natural-draft/4 25 12
Date