HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 11/05/2016Planning, Development & Transportation Services
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Community Development & Neighborhood Services
281 North College Avenue
P.O. 8ox'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
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Address:�.L-�--d t� �(/ Permit Number: [Q�
Approved Agency:
I hi'reby 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. n
Technician Name (print): N �c kNu LfvS _Company 2w mPrN N S 5 dG
Technician Signaturef-- s4" 1 Date ! s.
Appliance Tested: N (I W ►4-T-JAZ. AA F-
Appliance Replaced: `` t IL `(
Worst Case Conditions:
Spillage Duration (in seconds): C) Carbon Monoxide (parts per million): 1_
Pass -p_ Fail Date Tested: i,\ U _
Natural Conditions:
Spillage Duration.(in seconds): Carbon Monoxide (parts per million): _l
Pass )0 Fail Date Tested: I k 15; � I
(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
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CST:replacement/natural-draft/4.25.12
Date