RC-16-1461U
Permit Number
CONFIRMATION OF DROP'f J�S'I'
pc,-.�S-4 -1�561
Address q I ova"/S �� 1` �� 1 ' �Cfi ✓�+r` �oreg 331 3 c�
VQIJIPMF,NT USED: Y �MANOMETER
TIME: STAI-Z,Y �7%� F1NIS1.1
WC: 9 P- 1f 1� 2-
1 1;g*Z--V�V-60 live completed the above drop test in accordance 1%,ilh
NFPA 54 and Florida Bl.61ding Code (Fuel (,'as) and by signing this statement, I declare
under penalties of' pel jury that the test performed to be true, correct, antl colliple(c.
STATE 0 ,OI2 A JN AMI-DADS
r
Print Name Sworn to and s►ibserihed 1)efore n►e this (d
Sil;nalure of Notary Public_ Stale o1' hlorida
Sca I:
I'crsonally kII II _ OR, Produced Identification
Type of Idenlilicaliou Produced
of Se_ �! Y1Jo 201q
Y
Notary PubAe Stale of FbrxM
Maria E. Bre#oMY Corrxninm GG 129054
Expires 07272021
N PlZo)I':1INI: 3800 NW5911I s`ri1 b, ET, MIAM1, FL. 33142
(305) 635-4127