HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 05/26/2016_,• �� Community Development
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Collins 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
%i 970.416.2740
970.224.6134 (fax)
\ fcgov,com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 62,6 &KAcno �W dlr Permit #::l (46 9 29 \
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety est Guide Version 5, February 2012.
Technician Name (print): 3;djt�� t)V, Company ���`llriln sylU/( C�
Technician Signature: �J �V' Wt" Date 5 ?-li /Ze
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass X Fail
I( 7 I
Carbon Monoxide (parts per million): /?
Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail 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: repl acement/natura I-draft/4.25.12
Date