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�\ <br /> CITY OF EVERETT <br /> PIPING TEST AFFIDAVIT <br /> Owner /1� u r 1 � � nh �� �'�n - <br /> Job Address �_ ��U��� K <br /> �R.• PermitNo. f�D �O`� -d�Z <br /> The reirigerant line / atur / LP / medical gas system (circle one) was tested at �Psi for a <br /> totai of � � m' u �s. � <br /> WITNESSED BY � / � L� Date � �-�_ <br /> � ignaWre o occupan requesUng gas sernce Date <br /> INSTALLED BY ,�U w p� �` / %-�� <br /> u i � r � iS�iaiT i <br /> Please arrange for someone to be present on the date of requested inspection to provide access for <br /> the inspection. <br /> R[FRIGEFANT CONTA'NING PARTS OF THE SYSTEId THAT IS FI[LD EREGTED SIIALL BE TESTED FOR LEAK AT TEST PRESSURES NOT <br /> � FOR TESTING SHAOL1L BE T�HOSE LDISTED ON THE CONDEO-NSING UNIT IOR C�O 1PRESSOR UN T NAh EPLATE.WAC SE DZ S��B PRESSURE <br /> Hard Copy — Job Site Pink Copy— Contractor White Copy— Inspector <br />