HomeMy WebLinkAbout602 KEENESBURG CT - SPECIAL INSPECTIONS - 4/3/2017i
Planning, Development & Transportation Services
Community Development & Neighborhood Services
r C)f 281 North College Avenue
Fort Collins P O Box 580
Fort Collins, CO 80522.0580
Ltiy 970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: (&9e LC ,(/ � (,�`.!T_ Permit Number:
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. , Z-,- C <# 1J6�
Technician Name (print): /�c��il Company
Technician Signature: Date �
Appliance Tested: aA e-7gw- &Z!s � zftatE .' Gt'�.�T/2�/*k96)0
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): �(� Carbon Monoxide (parts per million):_
Pass )/ Fail Date Tested: 42-� /Dcz�/%
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.
Owner's Name (print)
Owner's Signature
CST:replacement/nattual-draft/4.25.12
Date