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HomeMy WebLinkAbout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ame as Facility Name or DBA-Doing Business As) %XVLQHVV6LWH$GGUHVV &LW\ =,3&RGH ,, 81'(5*5281'6725$*(7$1.6(59,&(7(&+1,&,$1,1)250$7,21 1DPHRI&RPSDQ\3HUIRUPLQJWKH&HUWLILFDWLRQ 3KRQH 0DLOLQJ$GGUHVV 1DPHRI8676HUYLFH7HFKQLFLDQ3HUIRUPLQJWKH&HUWLILFDWLRQ(Print as shown on the ICC Certification) &RQWUDFWRU7DQN7HVWHU/LFHQVH ,&&&HUWLILFDWLRQ ,&&&HUWLILFDWLRQ([SLUDWLRQ'DWH 0RQLWRULQJ6\VWHP7UDLQLQJDQG&HUWLILFDWLRQV(List all applicable certifications.) ([SLUDWLRQ'DWH ,,, 5(68/762)7(67,1*6(59,&,1* Indicate and attach the following reports if the monitoring equipment is capable of generating either.<11$0RQLWRULQJ6\VWHP6HWXS$ODUP+LVWRU\5HSRUW :DVDQ\PRQLWRULQJHTXLSPHQWUHSODFHG" (If “Yes,” identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) :DVGDPDJHGHEULVRUOLTXLGIRXQGLQVLGHDQ\VHFRQGDU\FRQWDLQPHQWV\VWHPV" (If “Yes,” describe what was found in section IV below.) ,VDOOPRQLWRULQJHTXLSPHQWRSHUDWLRQDOSHUPDQXIDFWXUHU¶VVSHFLILFDWLRQV" (If “No,” describe why in section IV below.) ,9 &200(176 If directed to use this section, describe how and when the issues were or will be corrected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anama-Buena Vista USD 4220 Ashe Rd Bakersfield 93313 16250 Meacham Road, Bakersfield, CA 93314 Aaron Perrigo 804904 8485827 9/16/2020 Veeder Root B47853 8/3/2020 Replaced 420 sensor in 87 Ann space and tested with BFD inspector Kris Karns Confidence UST Services, Inc. (800) 339-9930