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<br />' ,,''('P'1age 2 )
<br />MI~7E ID # OR PROSPECTING IpD # M' Qf~' f~`YW
<br />INSPECTION DATE ~ 1 ~ ~ ` S INSPECTOR'S INITIALS
<br />OBSERVATIONS
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<br />I & E Contact Address
<br />NAME _ ~ CI In ICI ~ -P
<br />OPERATOR ( (( s ~J Y
<br />STREET l ~ ~ ~ f ~ ~~-l ~1 1 _--- - _
<br />^ FS
<br />^ HW
<br />^ HMWMD (CH)
<br />^ SE
<br />^ WQCD (CH)
<br />^ OTHER
<br />CITY/STATE/ZIP
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