HomeMy WebLinkAbout531 S College Ave - Special Inspections/Combustion Safety - 06/23/2017Planning, Development & Transportation Services
Cif of Community Development 6 Neighborhood Services
Co ^ For North , CO 8 Avenue
®t1 P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
Icgovcom
Combustion Safety Test Compliance Form
Replacement Natural Draft Appliances in Existing Houses
Address:- 531 So, Permit Number , ��d 7•yZS
Approved Agency:
I hereby attest that 1 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. /J ff
Technician Name (print): �I>, Company A4,,
Technician Signature: Date Z
Appliance Tested: _l vA rig -pti��
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide art per million): 23
Pass (/ Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide arts per million):
Pass Fail Date Tested: l. 2 /
(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 1 have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature _
CST: replacement/natural-draft/4.25,12
Date