HomeMy WebLinkAbout6126 WESTCHASE RD - SPECIAL INSPECTIONS - 11/19/2018Planning, Development & Transportation Services
y community Development & Neighborhood Services
pp�� t �f�, g 281 North College Avenue
pm6rt C®{i gains P.O. Box 580
6 ` ii Fort Collins, CO 805220580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 1�5�5(✓ �Ul �7C0LLI11/$�crPermitNumber: rr3lB099(og
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
Technician Name (print):
Technician Signature:
Appliance Tested:
Version 5, February 2012.
,JGGIt U/ C,+-S6-)CwCt;
Date
INCi
Ih( Mc0*kQ07%Al Sc2#S-TYa2i
Appliance Replaced: 54M&hS 4BQV&
Worst Case Conditions:
Spillage Duration (in seconds): 05EC., Carbon Monoxide (parts per million):
Pass X Fail Date Tested: J'—I C —l8
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
l7P.
(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:replacemendnatural-draft>4.25.12
Date