HomeMy WebLinkAbout967 WAGONWHEEL DR - SPECIAL INSPECTIONS - 7/23/2015Planning, Development & Transportation Services
Community Development & Neighborhood Services
City
®f ®�� �O��' �� 2a1 North College Avenue
P.O. Box 580
Fart Collins, CO E0522.0680
970.416.2740
970.224.6134- fax
rcgovcom
Combustion Safety Test Compliance Form /
Replacement of Natural Draft Appliances in Existing Houses p��^�j n ✓
Address: % 7 (�%,. , U/ i� �� Permit Number: 9 60 ✓ U
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): 20 Company /'t9 C it
Technician Signature: �_ r/ `��� Date
Appliance Tested: 04ee, -
Appliance Replaced:!/Lv�rr�
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to convect 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-dralt/4.25.12
Date