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Facility <br />p <br />Impact Valve <br />1 J L <br />Contractor; <br />Address' <br />,State <br />Phone: <br />Technician: <br />, ,J <br />fV <br />I <br />Address <br />Cit , State:C;t <br />Test Date <br />9• �` <br />Type of test <br />I/I�. �<.� <br />Yes f oe.7}In <br />Test performed durin tine test? <br />Disp# <br />Grade <br />mpact Secure <br />Make Mount? <br />aive <br />Lock? <br />Passffail Com -nem Dtsp# Grade <br />Impact <br />Make <br />ecure alve <br />Mount? Lock? PaWl'ail Comment <br />NA <br />/r <br />R' <br />I <br />1i v <br />I <br />Impact Valve Testing -As <br />v7 <br />I` <br />ao <br />Ca <br />x <br />0 <br />F- <br />c <br />Q <br />,u <br />3 <br />a <br />X <br />LU <br />U <br />a <br />0 <br />z <br />00 0 <br />00 <br />