Cal. Code Regs. Tit. 21, div. 1, ch. 1, subch. 1, Applical Forms, app (j)
(j) Sample of Laboratory Verified Report.
SAMPLE OF LABORATORY VERIFIED REPORT
File No.________________
Application No.__________
Affidavit
THIS IS TO CERTIFY, That all of our tests and inspection of materials used in construction of the
Classroom Building
Alta Vista School, Alta Vista, California
were made in accordance with the approved plans and specifications and the rules and regulations of the Department of General Services and that all were reported to said department.
All the tests required by the approved plans and specifications were made.
I certify (or declare) under penalty of perjury that I have read the above report and know the contents thereof; that all of the above statements are true.
NORTHERN CALIFORNIA TESTING LABORATORY
By ___________________________________________________________________________
Signature of duly authorized representative
NOTE: If all the tests and inspections required by the approved plans and specifications were not made by the laboratory making this affidavit, those which were made should be either (1) outlined in lieu of the last sentence of the certificate or (2) covered by reference to a letter of instruction or check list, from the architect or engineer, a copy of which accompanies this affidavit.
(See Section 35)
Cal. Code Regs. Tit. 21, div. 1, ch. 1, subch. 1, Applical Forms, app (j)