HomeMy WebLinkAbout601 10TH ST - SPECIAL INSPECTIONS - 11/1/2012.......19, Uevdlo( ent & , i k anup%srw:-ui a
city O �Commuur �� Development a Neighborhood Services
P.O. BOX 680
FOr! Collins Fort Collins. CO 80522.0580
970.418.2740
970224.6134- fax
kgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: r�ol log ST-
Permit Number.
Approved Agency:
I hereby 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.
Technician Name (print):
Technician Signature: _
Appliance Tested-
Appliance Replaced: —
Company 5 w n�,J
Date I 2
Worst Case Conditions:
Spillage Duration (in seconds): 3 L Carbon Monoxide (parts per million):
Pass Fail 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 fatted 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
CSTXepkacement/natural-dra&4.25.12
Date