HomeMy WebLinkAbout1320 ALFORD ST - SPECIAL INSPECTIONS - 2/12/201411:37:05a.m. 09-20-2012 1 /t
Community Development
281 N. CogspAve.
PO Box 580
Fort Coliln% CO 80522
970.416.2740
970.224.6134 (fax)
fcgoxcom/devalopment
Combustion Safety Test Compliance Form
Replacement of Nauml Draft appliances In Rslsting Houses
Address: / 3 20 ro f OL !� Permif#
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Cc . Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print c_r ompany
Technician Signa r Date 2 l l
Appliance Tested: _
Appliance Replaced:
Worst ease Conditions: o
Spillage Duration (in seconds): Carbon Monoxide (parts per mullion): ' OU
Pass Fail Date Tested:
Natural Conditionns:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(balled test requires corrections nntll rest passes sender Natural Condidens)
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 aclntowledge that my appliance
bw failed a Combustion Safety Test under worst -case conditions. I aclmowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:replacement!natural-drati/4.25.12
Date