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EXH1Hl7 C <br /> K�1�l��a 1�1V�Illi� <br /> Vli. Inspectar Informaticn: <br /> 'Fhe inspections docurnentec�in the attachec� Inspection and Maintenance Checklists were <br /> conducted by the fvllawing inspector{s): <br /> Inspector Name and Title Inspeccnr's Ernplqyer and Address <br /> VIII. Certifica#ion; <br /> I.h.ereby certify,under penalty of per�ury,that the inft�rmation presented in this report and <br /> attachments is true and complete: <br /> Si�nature ofProperty(3wner or QEher Responsibl�Party Date <br /> Type or Print Name <br /> Carr�pany Name <br /> Address <br /> Phone number: Em�il: <br /> Page 3 O&Ad fnspection Report <br /> �T'�1��"1��15.151/La Pelme <br />