HomeMy WebLinkAbout1439 PAINTED DESERT CT - SPECIAL INSPECTIONS - 2/4/2015Cjof
Flirt Collins
Planning, Development & Transportation Services
Community Development & Nelghborhood Sorvlcea
281 Norlh C011ege Avenge
P.O. box 580
Fort Collins, CO 60522.0080
970.416.274o
970.224.5134-fax
lcgov.corn
Combustion Safety Test Compliance Form
Replacement of Natural Druft,Appliances in Txisting Mouses
Add.ress:
—J-143�—& �-C Pennii. Nurnber:26002-6
Approved Agency:
1 hereby attest that,] have been trained as an Approved Agency and have perfonned the 1:01lowing
Combustion Safety Test ill accordance with Fort Coltins Combustion Safety Test Guido
R Verlion 5, February 2012, 1
'l"cchnician Namc fnri
Technician Si.gnaturo:
Appllance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): ro
bass _✓ F'ai.f
Natural. Conditions:
Spillage Duration (in sec nds):�
I
Pass rail
Carbon Monoxide (parts per million):
Date Tested:
Carbon Monoxidc (parts per ill i)lioti):
Date Tested:
(Railed test requirm corrections to:tit test passes rutdrr Natural Co�zrlitiort.r.)
Technician Is recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
11
1. certify that I atn the legal owner oRhe 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 sbect.
Owner's Narne (priltt)
Owner's Signature
Datc
Cs'r:l•cp I at;cm ent/n atu ra I-drafV4..25.12
,4v,