TEST AGENCY QUALIFICATION SHEET
DATE _________
COMPLETED BY________
A.
Agency Qualifications
Agency Name ___________________________________________________________
Address _______________________________________________________________
Telephone Number ______________________________________________________
Years of experience testing industrial ventilation systems_____________
Industrial facilities tested (5 required). Include the following:
Facility Name, Address, Point of contact with telephone number;
Dates of test;
Type of operation tested;
List of Contaminants;
Number of fans;
Type of exhaust hoods;
Air cleaning devices; and
Personnel performing the test.
Attach letters of recommendation for tests performed at these facilities.
Three facilities shall be of the type of operation to be tested.
B.
Lead Test Engineer Qualifications
Name __________________________________________________________________
Length of time lead engineer has worked with Agency ___________________
Years of experience testing industrial ventilation systems ____________
Professional Engineering Information
discipline _____________________________________________________
license number _________________________________________________
issue date _____________________________________________________
recertification date ___________________________________________
state of registration __________________________________________
Industrial facilities tested (5 required). Include the following:
Facility Name, Address, Point of contact with telephone number;
Dates of Test;
Type of Operation;
List of Contaminants;
Number of Fans;
Type of Exhaust Hoods; and
Air Cleaning Devices.
SECTION 15951N
Page 13
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