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Yes No <br /> t Fire P mtectbn <br /> 9 RecmationalFacililiPs <br /> h. PubTUl;liti�s <br /> other <br /> Forthose checked 'yes,"phase elaborate whattype orkds of <br /> pmvem encs and/orassistance am needed. <br /> Ssinatsm: <br /> Address: 3 2 Po Yto t. Cif\U 114-3. 72,0 <br /> Te1phone: 8®a-3tiC.-0106 <br /> Date: /6//ii <br /> 6337A/50A -4- <br /> P .5/84 <br />