HomeMy WebLinkAbout1245 Lincoln Ave - Special Inspections/Combustion Safety - 07/13/2017Manning, Development & Transportation Services
Community Development & Neighborhood Services
ins
281 North College Avenue
Box
Fort CollForrtt Collins8 CO 80522 0580
970 416 2740
970 224 6134- fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: permit Number. �y
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test m accordance with Fort Collins Combustion Safety Test Guide
ersion 5, F bra 2012.
Technician Name (print):7Company i'1S7rVW C- o .
Technician Signature. - Date / i
Appliance Tested' YK c b;l 1-1122 -�✓
Appliance Replaced:
It t
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per illion)- - —�
Pass X— Fall Date Tested:
Natural Conditions:
Spillage Duration,(in seconds): �5 'cCarbon Monoxide (parts per !Ilion)•
Pass � Fail Date Tested: /
(Failed test requires corrections antil 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 Date
CST•replacementlnatural-draftA 25 12
1-00/1-00 d LOZ# ZZ OL 9LOZ/60/ZO 9990 bZZ OZ6 uny ole43ng woJj