HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 12/06/2016Planning, Development & Transportation Services
F6r. t Coltins
Community Development S Neighborhood Services
281 North College Avenue
P.O. Boz 580
Fort Collins, 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: �'r!i'� �?�'✓1�i'�/_ Permit Number:-D7�`-f S
Approved Agency:
I hireby 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 (print): Company
Y
Technician Signature: Date /Z
Appliance Tested:
Appliance Replaced: rc < r
Worst Case- Conditions: ,
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditions: 1
Spillage Duration,(in 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
19
CST:replac mendnabW-draft/4.25.12
Date