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Etanda ?

:Efow anany times you fiave


not .met the staadards in a year?
L2 Any relevant inforoation {f\r fouurron Loatrol Devices attached witfr tfie
I Imioerator)

Certified that the above report is for the period from .

Name and Signaftne of the liead of tbehstintion


Date:
Place

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