HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 9/19/2014o:- Community Development
�>l :'y 281 N. College Ave.
F
ort
Collins PO Box 580
Fort Collins, CO 8052=
• 970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: �/� ��d��, // ��� ���' ` ""'F l2M #: B / $—D 7
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
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Technician Name (print): J61 1cck Company
Technician Signature:avdA�JX q _. -d
I�'1/i " -- Date
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Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): 00 Carbon Monoxide (parts per million): ZI
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 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.
C�: ver's Lame (.print)
Date
CST_=e-Facemant nararaI-drain-i.25.12