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ELECTRIC: :: ENGINEERING . LIFE SAFETY QWA TECHNOLOGY AUTOMATION LIFE SAFETY SYSTEM RECORD OF COMPLETION This form is to be completed by the system installation contractor at the time of system acceptance and approval: It shall be permitted to modify this form as needed to provide a more complete and/or clear record. " . Insert N/A in all unused lines. Attach additional sheets,data,or calculations as necessary to provide a complete record. Form Completion Date: Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: Advent Health.Zephyrhills Address: 7050 Gall Blvd. Ze h rhills FL 33541 ". P Y Hos ital Description of property> P Name of property representative: Address: . . . Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: APG Electric, Inc. Address: 4825 140th Ave. North,St.Petersburg, FL 33762 Phone: 727-530-0077 Fax: E-mail: :. .. . . Service organization: . Address: Phone: . .. Fax: E-mail:. ... .. .... Testing organization: : APG Electric, Inc. Address: . 4825 140th Ave.North,St. Petersburg, FL 33762: Phone: Fax: E-mail: Effective date for test and inspection contract:. Monitoring organization: Address: Phone: Fax: E-mail: Accountnumber: Phone line 1: = Phone"line 2: -Means of transmission:.. . Entity to which alarms are retransmitted: Phone:. 3. DOCUMENTATION On-site location of.the.required record documents and site-specific software: 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑New system ❑■ Modification to.existing system Permit number: FIRE-001540-2021 Contractors EC0000486 I Engineers CA5947 1 4825 140th Avenue North I Clearwater, Florida 33762 1 T 727.530.0077 1 F 727.530.0045 1 www.apg.company