HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 05/19/2016-
Community Development
Fort
of 281 N. College Ave.
Collin s PO Box 580
Fort Collins, CO 80522
�i 970.416.2740
970,224.6134 (fax)
\ fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 920 Ad Not Permit##:
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name.(print):
Technician Signature:
Appliance Tested:
Appliance Replaced:
Company f&�✓�� P 6 Y
Date 5=/7-/�
Worst Case Conditions:
Spillage Duration (in seconds): (_ Carbon Monoxide (parts per million): /6
Pass —Z Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): l `i
Pass ✓ Fail Date Tested: 4 -/&'�
(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:replacement/natural-drat /4.25.12
Date