HomeMy WebLinkAbout3026 Rock Creek Dr - Special Inspections/Combustion Safety - 02/20/2018Planting, Dexreloptnen-L of
Community Development & tNetghborhood
281 North Cofte Avemie
P.O. Banc Soo
Fort CoMns. CO 80522.0580
970.224.6134- fex
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Combaselom Ssft Te
st�fl ce Form
laCCs®Mt of l��rso D 1M z3bftg 1HIos
P�9 PerrnitNumber.T,'1'�
A4pprova Aged
I hereby attest ta I have been tamed as in Approved Agency and have peed the following
Combustion Safety Test in accmdaice wilt Fort Collins Combustion Saft Test Guide
Version 5, February 2012.
Technician Name (prsnt): 1 P nm isompEw S-2NM
TecbnWm S Daft
Appliance Tested:
Appliance Replaced: &Cjoau
Wont Que CoadMoms :
Spillage Duration (m seconds): Carbon Monoidde (parts per million):
Pass. )C_ Fail Daft T do [ L�
Nattaan° A Coadffiowo
Spillage Duration (in seconds): Carbon Monaidde (parts per mMon):
Pam Fail Daft Tssbd-.
(F yes and saes wrN )
Technician's recommendations to correct tested appliance failure:
Fafled Worst COMMOne
I =y that I am the legal owner of the above listed proptnty and hmby aclmowledge that my appliance
has befled a Combustion Safety Test under aomafl ems. I aclaeowledge that I have received a
combustion appliance safety informsion sheet.
owner's Name (prmt)
Owner's Sim Dame
4IS.12