HomeMy WebLinkAbout900 ROCKY MOUNTAIN WAY - SPECIAL INSPECTIONS - 9/26/2013�0 Mt4�
Planning, Development & Transportation Services
City of Community Development s Neighborhood Services
281 Fort Collins For Collins, College 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
Address: _ VA 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
Technician Signature:
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Company
Date 13
Spillage Duration (in seconds): �_ Carbon Monoxide ( rts per million): Q
Pass Fail Date Tested: 43 /,�
Natural Conditions: "NN
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes tinder 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-draft/4.25.12
Date