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HomeMy WebLinkAbout2202 Owens Ave - Special Inspections/Combustion Safety - 11/07/2017Fort Collins Planning, Development & Transportation Servi6es 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 uleccj 11 - i 4--1, Replacement of Natural Draft Appliances in Existing Houses V- ,! Address: o�o� 016 W E/US ,A VEI a / o 1 F�C, Permit Number. � i 7�d 7 0 6 �. Approved Agency: Go -2 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 (pnnt). E GAWLO Company,A641r tg -L:!�Ef- Technician Signature s Date Appliance Tested: w Y© CAL S Z✓ 114 Appliance Replaced: MAte 4S . 016- Worst Case Conditions: p Spillage Duration (m seconds) 20 MiCarbon Monoxide (parts per million) ...,ye—fPA Pass Fail Date Tested: 9 —7- ^ 17 Natural Conditions: Spillage Duration (m 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