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Yes No <br /> e. P olhe P ratPcibn x <br /> i. Fire P rmtection >` <br /> 9 Recr_eadonalFaciliths <br /> - <br /> X <br /> h. P ub It U tslii s <br /> X <br /> Other <br /> For those checked "yes",phase e3aborate w hattype or kinds of in pmvem ents <br /> and/orassistance are needed. <br /> S i�natur�: dMg,4� Q.- P/ <br /> • <br /> Address: 75-938 ii/DIA sr. /yoz.c tz)A 1 / z -9 725 <br /> Telhphone: gOe • 3q-c- Scg <br /> Date: Or- 26 - �5 <br /> -9- <br />