HomeMy WebLinkAbout4107 WAYNESBORO CT - SPECIAL INSPECTIONS - 11/15/2012Jan 03 13 08:17a Francisco Manzano 8705061686
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances In Existing Houses
Address: 4 1 ():] L 5 B Q tJ e 5PezrnitNumber. f-1?06c?167
Approved Agency:
I hereby attest that I heave been trained as an Approved Agency and have performed the following
Combustion Safety Test in scoordavice with Fan Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (prim): FA2"1 se-4 MAAIZwo Company-6dS&O ?ZvllfSlAfc z
Technician Signature: _)L/A
Appliance Tested,—IVA,4d4'
Appliance Replaced: LIVate4- qCaix4Z
Date 1/- 15 - Z
Worst Case Conditions:
Spillage Damtioj2(in swmds).-k-19,L-i2 Carbon Monoxide (parts per rninion)- IR-115 -L-�5
Pass VFail — Date Tested: -// - IS-1 Z
Natural Conditions-.,
Spillage Duration (in secon&):
Pass Fail
Carbon Monoxide (parts per million):
Date Testetl--
(Fafied test requaw COM*tdons JVff*I react passes under Nawrdd Confiaon&)
Technician's rmwimendations to Oorrm =ted applia= failure:
Failed Worst Case Conditions:
I Certify that I am the legal owner of the above listed PrOPCrtY and hereby acknowledge that ray appliance
has f"U04 a Combustion Safety Test under worst -case conditions. I admowlvdge that I have received a
combustion appliance safety mfornumon sheet
Owner's Name (print)
Owner's Signature _
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Date