HomeMy WebLinkAbout1901 Real Ct - Special Inspections/Combustion Safety - 08/18/2016Planning, Development & Transportation Services
C {t og Community Development a Neighborhood Services
1 281 North College Avenue
Fort Collins Fort Colli s8 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: AW ,/ � �`� Permit Number: 'gI 4b 413�1
Approved Agency:
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
r,Version 5, Febru�2012.
Technician Name (print): /%/� 0 Company /C1
Technician Signature: Date
Appliance Tested:
Appliance Replaced:��
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested: 1e
Natural Conditions:
Spillage Duration (in seconds): _
Pass Fail
Carbon Monoxide (parts per million):
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