HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 10/14/2017N
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N. _ge Ave.
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Fort Colitns, CO 80522
970. I&V40
970.224.6134 (fax)
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: (,6-2,0 ` �(.� QX �GZM /LQ,(i 16 10-7 _ Peimit #:2'j01 � Z
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test m accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
TechnicianWama(pmQ 5 `Ear ,_Company
Technician Signature: Date /b —
Appliance Tested: `(o 4t '.` C ✓ ,C f�l� { �/G
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (irI seco }: t{ . Carbon Monoxide (parts per million): � 3
Pass Fail Date Tested: I e I y 7-
Natural Conditions:
Spillage Duration(ii seconds): 2- Carbon Monoxide (parts per million):
Pass _jZ Fail Date Tested: / d0/ Y 11
(Failed tmt requires corrwoous until test passes under Natural Csn"ons)
Technician's recommendations to correct tested appliance failure:
Failed Wgrst 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 -ease condition. I admowledge that I have rived a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature _ Date
CSTp 424.I2