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1 / <br /> m�:_t•..�� :..s.........7...Jlr......ai...nis.fr.snt.,ro nn..ina..Nisso r.orilVfir tv FYliK7/t{f%.�'�.ve[:n's7a�f�ti i,V�t`t7tYui�C�r."saroiiz�t.�. ...._ ...._ <br /> f rfau/.AI Of.0 u+w,wacau Jw a.as.+.J vvr...a.........1....�..,....-.['.�-..-...- •--""o 'r -- - <br /> oppt,opriate pages of ijusfonn to report resuits for a!f components tested The c9mp1e!ed kT.m,wrr+den les!pr ..dare e <br /> svaissr/ti+rra{rnrw tune!if'rrnniirnhlvl vhr,r,Zd he provided to the fadfi awner'ODe:wor for Submittal to#w 70c^•l''i0pp��f;k##nr,r <br /> tV b" ! <br /> 1. FACILITY MFORMA'rION <br /> Facility Name: jq p r_ G he!;lVo H ( .*are of i=mg. j fir- -r -or tyy ' <br /> Facility Address:'-,' S _. ' t £ 1-e'P�,: r r•� 9 s .4 <br /> Facility Contact: Q i Phone: 2.o pq <br /> ' Tloto 7,vwl Aannt-af u7aa NntifitYi of Te_at]nsr' PL; :, ..� r o_,-s... �, �+ <br /> Name of Local Agwcy Inspector(if preseni dluring lestinz. <br /> 2. TL'ST ' C C v"i - ^TOIL Il'a FORMAT101%i <br /> z-w„ �ri rn:i�c: .J rc it to <br /> _ <br /> Tectmician Conducting Test: ,�r - <br /> Credettfrgt-: a CSIB Ucaused CanaraCtor L,S Wn1 CE-F t..ic4M 1 . -e-C-1 <br /> 1 T irr+neo Tvne..; mwNumber: 7t4 <br /> Not i R�rS`- - -- ! I Not Repairs <br /> US <br /> �il.u►)flYifiii i Pi a',=i.... ... i .�_st_ CoP..`t. i P as i Fall R•�.ae.i i/...1� <br /> 1 C81l1)I f]l Puw` <br /> J� in�� i S �? ! ! ❑ ❑ ❑ Sem,,d a� t*'* J` I-iii- 4 ❑ u <br /> / V7 <br /> 1 ► n I n, n f ► I n i n 1 n - <br /> r - <br /> W t L1 ii <br /> 1 a © I I ! 1 cj <br /> Iii I:_..u j ui._i <br /> 14 <br /> t-i it v w% aLi -1 9 �- <br /> ..scaifi,�rlWtsa acas,�v�:fray-.r..._wftj. ,i-,.....:i....�.L..a .. .1wwA w..:tia-41.n<<.n4ar nQnw-nn«wwint nw.of mote• <br /> lY„�t,xV7lA,fl. } .acuw►•ifsn.w++.na .:ice.v..........au r.av..saws.raw. wujv.v..............,..... <br /> CERTIF-CA N OF TECH NIrIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofnty k� *e tfasts stated in tidy41 oe ment are acAWafe•.ana in„ compliance wink ftot re alrewa& <br /> I'ecbrn cian 8 Signature; -� --i - Dale. c.. <br />