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HOUSE HE <br />ADDRESS S <br />OCCUPANT <br />HEAT LOSS DATE HTG. INST. <br />.OLD BY ----- �. <br />Electrical Work By -- <br />TYPE OF HEAT GA _ __ _ FA .�f HW r..7EAM <br />G S DESIGN <br />ING TEST RECORD <br />APT. FLOOR _ CITY ____ _ . _ SUBURB <br />OWNER <br />INSTALLED BY <br />Gas Line By�— <br />SPACE HTR. UNIT HTR. OTHER <br />CONVERSION <br />MAKE I- _ MAKE OF BURNER <br />Modal — _ Iv Modal _ __ <br />Serial �_ ___—_____ Max. BTU Rating <br />MAKE OF FURNACE <br />Model <br />CONTROLS <br />THERMOSTAT_)j LH <br />Heat Plug <br />Vent Size <br />'/_)j <br />Valve _ _.,fig tetC� <br />1 . _ <br />KIND OF LINER L _ <br />SIZE -i'_ NONE <br />Limit _ _-- !_-_--- <br />-- _ Draft Hood __. <br />Regulator <br />Limit Setting.-. _—._- <br />Filters Size __Lle,.t-----Numiar—_( <br />-- _ <br />Fan Setting <br />Chimney Location <br />Inside <br />�� Outside <br />Pilot Type <br />Chimney Construction11e <br />LtL - <br />Pilot Melo <br />Pilot Modal _. <br />_ Smoke Bomb - - -- <br />—Wiring <br />Pilot Timing -- <br />_ _ Draft <br />—Test Tog f <br />L.W. Cut Off?? _ <br />Door Pressure <br />Lighting Inst. <br />Pressure--Aic.�'� �_ <br />Percent CO <br />LLQ--- Date Tested A <br />'204 ` <br />V <br />Input CFM ` <br />Percent O 2_ <br />Company Testing _ <br />1 <br />_ <br />Steck Temp. `s) A%—__ <br />Percent CO <br />_ Name of Tester <br />Form 23S <br />