HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 9/16/2015= 281 N. College Ave.
� " COUDISIOX&ISFo Sox 5B0;.�; a:yFort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov com/development
Combustion Safety 'Feat COMPHance Form
Replace;dient of Natural Draft Appliances in Rdsting Houses
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Address: �C`.�v'� '�e��P. DL�!j� �� r �i�r nr e Permit #:
AppIroved 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.
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance. Replaced: wl-i . :
Woxlst Case Conditions:
Spillage Duration (in seconds):
Pass Fair
Natu' rol Condlitions:
Spillage. Duration (in seconds):
Pass Fail
Company } f % V"
Date�'±tls 'J
Carbon Monoxide (parts per million):
Date Tested:
r• r.
Carbon Monoxide (parts per million):
Date T ested:
(Failed test requires corrections wz& test passes tinder Natural Conditions)
Technician's recommendations to correct tested appliance failure:
Failed . orst Case Conditions:
1 cer?f-v ?liar I am the legal owner o f the above listed property and hereby acknowledge that my appliance
f ailed a Combustion Safety- Tesr unde-r worst -case conditions. I aelmoviledse that I have received a
Date