| Facility Name: | ______________________________________ |
| Facility Address: | ______________________________________ |
| Date(s) of Construction: | ______________________________________ |
| Date(s) of Alteration: | ______________________________________ |
| Number of Stories and Size of Each: | _________________________________________________ |
| Name(s) of Surveyors: | _________________________________________________ |
| Date(s) of Survey: | _________________________________________________ |
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