HomeMy WebLinkAbout6453 Rookery Rd - Special Inspections/Combustion Safety - 01/19/2018 (2)City Of Community Development
Collins 281 N CollegeAve
PO Box 580
F6rt
Fort Collins, CO 80522
970 416 2740
970 224 6134 (fax)
fcgov com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address r -� � �Permit#� /-- VV2�Z
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) h V /�S Company q
Technician Signature Date
Appliance Tested
Appliance Replaced Sl r Y V t"
Worst Case Conditions: � Q 'Z )
Spillage Duration (in seconds) Carbon Monoxide (parts per million) (p
Pass Fail Date Tested: , —/ I'
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail/ Date Tested:
(Failed tes�ires corrections until test passes under Natural Conditions)
Technici�ia%Srrecommendahons 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