HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Special Inspections/Combustion Safety - 01/14/2017v Planning, Development&Transportation Services
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Combustion Safety Test Complianee Form
Replacement of Natural Draft Appliances in Exlsift Souses
Address: -Sb20 L Permit Number. 9 t 0 D 31 l
Approved Agency: 6 v�•'� 3° �. F�
TechnicianName(psini):
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Technician Signature: `�� Date
Appliance Tested: a ..
Appliance Replaced: O / N 6✓�
Worst Case. Conditions:
��//� Carbon Monoxide _ arts per million): /o -
spillage Duration (in seconds): �
Pass Fail DeieTeated: �y
(Failed test requires owner's signature acl amvled&g resulfs)
Natural Conditions:
Spillage Duration Cm seconds):
Carbon Monoxide (pans per milli a):
.Pass Fail Data Tested:
(Failed test reguh--corredlons until test posses under Natural Condido")
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Technician's recommendations to correct tested appliance failure:
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 admowledge that
I have received a combustion appliance safety information sheet.
Owner's Name (print)
owner's Signature
Date