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BV Lab Number: Technician Name:

Test Date:

Reviewed By/Date:

Key:

* Additional Charge For This Test ** Mandatory Requirement # By Request Only

Result Key:

C Claimed R Recorded M Meets

NM Does Not Meet NA Not Applicable NT Not Tested

Rating Key: PASS Pass FAIL Fail

Creation Date:

SEPTEMBER 02, 2010 Last Revision Date: SEPTEMBER 22, 2011 Pricing Review Date: Technical Review Date: