Building Inspection Please make sure to fill out every section of this form. Building Inspection Inspector Information Inspector Name * Inspector Name First First Last Last uNID * Inspector email * Safety Committee * Please Select From List or Begin TypingCollege of Architecture + PlanningCollege of EngineeringCollege of Fine ArtsCollege of HealthCollege of HumanitiesCollege of LawCollege of Mines & Earth SciencesCollege of NursingCollege of PharmacyCollege of Social and Behavioral ScienceCollege of Social WorkCollege of ScienceDavid Eccles School of BusinessHuntsman Cancer InstituteJ. Willard Marriott LibraryRed Butte GardenSchool for Cultural and Social TransformationSchool of DentistrySchool of MedicineSpencer S. Eccles Health Sciences LibraryUniversity of Utah Real Estate Administration Date * Building * 0 - Unknown1 - John R. Park Building2 - Voice & Opera Center3 - David P. Gardner Hall4 - Joseph T. Kingsbury Hall5 - George Thomas Building6 - William Stewart Building7 - Life Science Building8 - Alfred C. Emery Building9 - John A. Widtsoe Building10 - Physics Building11 - William C. Browning Building12 - Frederick Albert Sutton Building13 - LeRoy E. Cowles Building14 - James Talmage Building17 - Performing Arts Building19 - Intermountain Network Scientific CC25 - Social & Behavioral Sciences26 - College of Social Work27 - Social Beh. Science Lecture Hall28 - Alice Sheets Marriott Center for Dance29 - Einar Nielsen Fieldhouse30 - Cauldron Legacy Plaza Visitors Ctr32 - Rice-Eccles Stadium33 - Spence Clark Football Center35 - Marcia & John Price Museum Bldg36 - Film and Media Arts Building37 - Architecture Building38 - Art Building39 - Sculpture Building40 - Student Services Building41 - Northwest Parking Garage43 - Naval Science Building44 - Office Building 4445 - Carolyn Tanner Irish Humanities Building49 - Language & Communication Bldg51 - Sterling Sill Center52 - Alumni House53 - A. Ray Olpin Union56 - Civil and Materials Engineering57 - Hedco Building58 - Mineral Processing Lab59 - Mining Systems Research Lab60 - Experimental Studies Building61 - Floyd and Jeri Meldrum Civil Engineering Building62 - John and Marva Warnock Engineering Building63 - John and Marva Warnock Engineering Building (L)64 - Joseph F. Merrill Engineering Building65 - Milton Bennion Hall66 - Roy W. & Elizabeth E. Simmons Pioneer Memorial Theatre67 - University Campus Store69 - Central Parking Garage70 - S.J.Quinney College of Law71 - Beverley Taylor Sorenson Arts and Education Complex72 - Building 7273 - Building 7374 - Business Classroom Building77 - C. Roland Christensen Center79 - Spencer Fox Eccles Business Building82 - Aline Wilmot Skaggs Biology Building83 - James C. Fletcher Building84 - Biology Building85 - Henry Eyring Chemistry Building86 - J. Willard Marriott Library87 - Thatcher Building for Biological and Biophysical Chemistry90 - Jon M. Huntsman Center91 - HPER East92 - HPER North93 - HPER Natatorium94 - HPER West95 - HPER Building Mech S/W96 - HPER Building Mech S/E97 - Dumke Gymnastics Center98 - Kenneth P. Burbidge, Jr., Family Athletics Academic Center99 - Jon M. and Karen Huntsman Basketball Facility103 - Playfield RR & Concessions105 - Annex General Office108 - Golf Pro Shop109 - Dumke Family Softball Stadium110 - George S Eccles Student Life Center111 - McCarthey Family Track and Field Storage Building112 - Donna Garff Marriott Residential Scholars Community116 - Commuter Services Bike Barn119 - George S. Eccles 2002 Legacy Bridge124 - Building 124126 - Biology/Theatre Storage130 - Olympic Cauldron149 - North Campus Chiller Plant151 - James LeVoy Sorenson Molecular Biotechnology Building - A USTAR Innovation Center170 - Fine Arts West171 - Campus Bike Shop179 - Dolores Dore Eccles Broadcast Center180 - Space Planning & Management182 - Meldrum House184 - Sponsored Projects190 - Institute Parking Structure197 - Rosenblatt House198 - Eccles House200 - University Kids205 - George S. Eccles Tennis Center Indoor206 - George S. Eccles Tennis Center Outdoor210 - Spence and Cleone Eccles Football Center212 - Spence Eccles Field House213 - Library Storage214 - Storage Bldg 214215 - Shop Building216 - Ski Building219 - Baseball Dugouts255 - Sugarhouse Clinic258 - Dermatology South Clinic260 - Park City Ski Clinic263 - Moran Vision Center274 - So Jordan Family Practice Clinic301 - Public Safety302 - East Campus Chiller/HTW Plant303 - High Temperature Water Plant304 - Grounds Storage Building305 - Physical Plant Services306 - Buildings & Grounds308 - Recycling Center309 - Motor Pool Building317 - Motor Pool Gas Station320 - Red Butte Trailer323 - Red Butte Greenhouse324 - Red Butte Equipment Bldg325 - Red Butte Garden Rose House327 - PPO Greenhouse329 - Arboretum Greenhouse331 - Deep Well #1 (Stad Parking)332 - Pumphouse #2 (Stad)334 - Pumphouse #4335 - Pumphouse #5 (Sill)336 - Pumphouse #6 (Bus)337 - Pressure Station (Naval Sci)338 - Pumphouse #8 (Vn Cot)341 - Electrical Substation stadium342 - Electrical Substation Med Ctr343 - Electrical Substation RB Creek347 - Steam Generating Plant348 - Storage Huts349 - Transformer Building350 - V. Randall Turpin University Services Building361 - Pressure Station #5 (Browning)362 - Pressure Station #2 (Dumke 535)363 - Pressure Station #1 (EE Jones)364 - Pressure Station #3365 - Pressure Station #4 (NW of #660)366 - Primary Children's Outpatient Services Building369 - Ambulatory Parking Structure370 - The Children's Center372 - Rio Tinto Kennecott Mechanical Engineering Building373 - Primary Children's Parking Terrace (Lot 48)374 - Primary Children's Medical Center379 - Children's Special Needs Clinic381 - Bus Shelter #1 ("HPER stop")382 - Bus Shelter #2 ("Huntsman stop")383 - Bus Shelter #3 ("S. Campus/LDS stop")384 - Bus Shelter #4 ("PCMC stop")385 - Bus Shelter #5 ("Kennecott stop")386 - Bus Shelter #6 (Reserved for a future "Sutton stop")387 - Bus Shelter #7 LAW stop388 - Bus Shelter #8 ("Social Work stop")389 - Bus Shelter #9 (across street from Soc Wk)390 - Bus Shelter #10 (SE from FAMB)391 - Bus Shelter #11 (SE corner Pres Cir)392 - Bus Shelter #12 ("Ozone Stop")393 - Bus Shelter #13 ("Med Ctr. Trax Stop")394 - Biology Growth Site395 - Bus Shelter #15 Arapeen Stop396 - Bus Shelter #16 "Ortho Stop"439 - Department of Chemical Engineering440 - Institute for Clean and Secure Energy Shop441 - Institute for Clean and Secure Energy Office443 - Institute for Clean and Secure Energy Storage444 - EGI Sample Storage445 - Warehouse Storage Building446 - University Neighborhood Partners #1447 - Physics Shop Bldg448 - Davis Dialysis Center (Lakeside)458 - KUEN Communications Facilities - multiple sites471 - Farmington Bay Dialysis472 - Yellowstone Dialysis473 - Iron Mission Dialysis Center474 - Bonneville Dialysis Center475 - Castleview Dialysis Center476 - Dixie Dialysis Center477 - Gem State Reg Dialysis Center478 - South Valley Dialysis Center479 - Provo Dialysis Center482 - 102 Tower483 - 525 Plaza484 - Univ Health Sciences 515 Tower485 - U Hospital Business Sevices Building Parking Terrace Downtown489 - University Business Services Bldg490 - St. Mark's Hospital Clinics492 - Dugway Seismograph500 - Nora Eccles and Richard A. Harrison Building512 - Research Administration Building515 - Storage Bldg. 515516 - Radiological Health Storage Bdg 516521 - School of Medicine522 - West Pavilion (Hosp)523 - John A. Moran Eye Center524 - Medical Center Parking Terrace525 - University Hospital526 - Hospital Generating Plant527 - University Hospital Parking Terrace (Lot 50)529 - George S. and Dolores Dore Eccles Critical Care Pavilion530 - Maxwell M. Wintrobe Research and Education Building531 - Medical Research & Education Bldg532 - West Pavilion Generating Plant533 - George and Dolores Eccles Institute of Human Genetics535 - Ezekiel R. & Edna Wattis Dumke Building540 - Health Science Parking Center543 - Heating Maintenance550 - Clinical Neurosciences Building554 - Huntsman Cancer Institute Annex555 - Huntsman Cancer Institute556 - Huntsman Cancer Hospital560 - HCI Garage (Lot 68)561 - HSC North Parking Terrace & Helipad (Lot 51)565 - Emma Eccles Jones Medical Research Building570 - Biomedical Polymers Research Bldg575 - Spencer F. and Cleone P. Eccles Health Sciences Education Building581 - L.S. Skaggs Jr. Research Building582 - L.S. Skaggs Hall585 - Radiobiology Lab586 - Radiobiology Administration587 - Comparative Medicine Center588 - Annette Poulson Cumming College of Nursing Building589 - Spencer S. Eccles Health Sciences Library590 - Regulated Waste Management Facility601 - Fort Douglas Duplex602 - Fort Douglas Duplex603 - Fort Douglas House (Interfaith)604 - Pierre Lassonde Entrepreneur Center605 - Environmental Health & Safety606 - Fort Douglas Duplex607 - Emma Eccles Jones Fine Arts House608 - S.J. and Jessie Eccles Quinney House609 - First Security House610 - Poulson House611 - Kennecott House612 - O.C. Tanner Humanities House613 - Gary and Ann Crocker Science House614 - Lowell Bennion Service House615 - Fort Douglas Duplex616 - Fort Douglas Duplex617 - Fort Douglas Duplex618 - Fort Douglas Triplex619 - Fort Douglas Honors Center620 - Fort Douglas Commander's House621 - Fort Douglas House622 - American Indian Resource Center623 - Fort Douglas House624 - Fort Douglas House625 - Fort Douglas House626 - Fort Douglas-Residential Storage627 - Fort Douglas-Property Surplus631 - Fort Douglas Museum632 - Fort Douglas Museum634 - Fort Douglas Bandstand636 - Fort Douglas Theatre638 - Fort Douglas PX639 - Fort Douglas R.R.640 - Fort Douglas Bowling Alley643 - Fort Douglas Storage (Res Liv)644 - Fort Douglas PO Shops645 - Fort Douglas Storage (Plumb)648 - Fort Douglas Chapel649 - Fort Douglas Officers Club650 - Ft Douglas- Bath House652 - LEAP House653 - Fort Douglas House655 - Fort Douglas Museum656 - Fort Douglas Duplex657 - Fort Douglas Duplex658 - Fort Douglas Duplex659 - Fort Douglas-Public Safety660 - Fort Douglas Duplex661 - Fort Douglas House662 - Fort Douglas House663 - Fort Douglas House664 - Fort Douglas Duplex665 - Fort Douglas-Red Butte666 - Fort Douglas-Red Butte670 - Outdoor Recreation Boat House676 - Fort Douglas Residential Living685 - Edwin L. & Grace G. Madsen Clinic701 - University Student Apts Tower 1702 - University Student Apts Tower 2706 - Univ. Student Apts Townhouses 3707 - Univ. Student Apts Townhouses 2720 - Univ. Student Apts Maintenance Fac721 - University Student Apts Office722 - University Student Apts Storage723 - University Village West 100A724 - University Village West 100B725 - University Village West 100C726 - University Village West 200A727 - University Village West 200B728 - University Village West 200C729 - University Village West 200D730 - University Village West 300A731 - University Village West 300B732 - University Village West 300C733 - University Village West 300D734 - University Village West 400A735 - University Village West 400B736 - University Village West 400C737 - University Village West 400D738 - University Village West 500A739 - University Village West 500B740 - University Village West 500C741 - University Village West 500D742 - University Village West 600A743 - University Village West 600B744 - University Village West 600C745 - University Village West 600D746 - University Village West 700A747 - University Village West 700B748 - University Village West 700C749 - University Village West 100D750 - University Village West 800A751 - University Village West 800B752 - University Village West 800C753 - University Village West 900A754 - University Village West 900B755 - University Village West 900C756 - University Village West 900D757 - University Village West 1000A758 - University Village West 1000B759 - University Village West 1000C760 - Univ Village West Comm Center761 - University Village East 1100A762 - University Village East 1100B763 - University Village East 1100C764 - University Village East 1100D765 - University Village East 1200A766 - University Village East 1200B767 - University Village East 1300A768 - University Village East 1300B769 - University Village East 1400A770 - University Village East 1400B771 - University Village East 1400C772 - University Village East 1400D773 - University Village East 1500A774 - University Village East 1500B775 - Univ Village East Comm Center801 - University Guest House802 - Chapel Glen 802803 - Chapel Glen 803804 - Chapel Glen 804806 - Gateway Heights 806807 - Gateway Heights 807810 - Sage Point 810811 - Sage Point 811812 - Sage Point 812813 - Sage Point 813814 - Sage Point 814815 - Chase N. Peterson Heritage Center820 - Benchmark Plaza 820821 - Benchmark Plaza 821822 - Benchmark Plaza 822825 - Shoreline Ridge 825826 - Shoreline Ridge 826827 - Shoreline Ridge 827828 - Shoreline Ridge 828829 - Shoreline Ridge 829830 - Shoreline Ridge 830837 - Atmospheric Sciences - Mountain Meteorology Lab840 - Ray & Tye Noorda Oral Health Sciences Building841 - Ray & Tye Noorda Oral Health Education Parking Structure845 - Red Butte Garden Amphitheatre846 - Richard K. Hemingway Orangerie848 - Em's Sprout House849 - Walter P. Cottam Visitors Center851 - 590 Wakara (UU Orthopaedic Ctr)852 - UU Orthopaedic Ctr Parking Garage853 - Dr. Ezekiel R. and Edna Wattis Dumke Health Professions Building854 - 505 Wakara Way856 - 423 Wakara Way857 - 421 Wakara Way858 - Human Resourses859 - 419 Wakara Way860 - 417 Wakara Way (Biomed Research Bldg)865 - 295 Chipeta Way866 - 295 Chipeta Way Parking Structure870 - 500 Huntsman Way (Huntsman Corp)872 - Natural History Museum of Utah873 - Reserved for BioFire Diagnostics Building874 - 383 Colorow Drive876 - 375 Chipeta Way878 - 391 Chipeta Way879 - 515 Colorow881 - 501 Chipeta Way (UUNI)884 - 546 Chipeta Way (ARUP)886 - 615 Arapeen (Paradigm 1)887 - 675 Arapeen Drive (Paradigm II)888 - 729 Arapeen Drive (INC)890 - 540 Arapeen Drive892 - 585 Komas (Consolidated Data Ctr)894 - 606A Blackhawk896 - 650 Komas901 - UUHN - Greenwood Center902 - UUHN - Parkway Center903 - UUHN - Westridge Center904 - UUHN - Redwood Center908 - UUHN - Stansbury Medical Center915 - UUHN - Davis Center916 - UUHN - Redstone Center917 - Speech Language Hearing Clinic918 - Centerville Clinic942 - Band Storage944 - Parking Services Temporary Office 1945 - Parking Services Temporary Office 2946 - Parking Services Temporary Office 3947 - Parking Services Temp Office #4952 - AirMed Quarters Park City954 - Moran Trailer3000 - Utah System Higher Education3012 - Office of Legislature Research3030 - Department Of Neurology3031 - UNI Residential Treatment Center3100 - UU Midvalley Health Center3101 - Washington Federal Bldg3105 - UNI Wellness Recovery Center3110 - Fashion Sq #33113 - Fashion Sq #43114 - Murray Park Building3270 - SL Valley Detention Center3401 - Department of Surgery / otolaryngology3402 - American Fork Dialysis3404 - Sorenson Global Impact Investing Center3439 - Erda Self Storage3440 - AA Alpine Storage3441 - Sugarhouse Self Storage3442 - Department of Chemical Engineering3448 - Clinics at the Utah Valley Regional Medical Center3454 - CECE - Bountiful Site3458 - Lon and Mary Watson Millard County Cosmic Ray Center3459 - Dinwood Building Storage3460 - VA - Building #13464 - VA - Building #23465 - VA - Building #143466 - VA - Building #33467 - VA - Building #73475 - Tonaquint Data Center in St George3476 - Utah Lions Eye Bank3477 - Medical Office Building SL Regional Med Ctr (Holy Cross)3478 - Mountain View Orthopedic Center3486 - VA Hospital Bldg #453487 - CECE Sandy3491 - Seismograph Stations3502 - Pediatrics S. Main Clinic3512 - Faculty Club Lodge3516 - Air Med Hanger SLC Airport3521 - Brigham City Fine Art Center3523 - Scorup House College of Architecture3524 - Nayon Heights Condominium Unit 6 Building G3525 - Eastside Place Apartments3529 - American Towers Condominium3533 - UU Press Chicago Distribution Center3541 - Beneficiary Deed Townhome Tucson3546 - Stonebridge Plaza Apts3551 - Cloverland Building3553 - Physics Residence 53554 - Middle Drum Fluorescence Detector Building3555 - Black Rock Mesa Fluorescence Detector Building3556 - Long Ridge Fluorescence Detector Building3557 - Black Rock Mesa Electon Light Source3559 - Rio Mesa Center - Small Barn3561 - Rio Mesa Center - Large Barn3562 - Rio Mesa Center - Enclosed Gazebo3563 - Rio Mesa Center - El Shack3564 - Rio Mesa Center - Deck House3565 - Rio Mesa Center - Dalton House3566 - Rio Mesa Center - Tack Shed3567 - Rio Mesa Center - Tank Shack3568 - Rio Mesa Center - Susan's Shed3569 - Rio Mesa Center - Susan's House3570 - Desert Valley Dialysis Ctr3571 - Hurricane Dialysis Ctr3572 - Pleasant View Dialysis3573 - Wasatch Kidney Specialists Dialysis Ctr3574 - 875 S. West Temple3576 - VA Hospital Bldg # 303577 - VA Hospital Bldg # 373579 - CECE Dixie College Site3580 - West Valley Dialysis Center3582 - Air Med - Rock Springs3586 - Payson Regional Dialysis Center3587 - Ob-Gyn Clinic - Avenues3589 - Air Med - Tooele3590 - Physics Residence 13591 - Physics Residence 23592 - Physics Residence 33593 - Physics Residence 43594 - Brigham Apartments, 8253601 - Downtown Commons One3602 - Downtown Commons Two3604 - Mark Lindsay Dialysis Center3605 - Kearns Building3607 - Willard L. Eccles Observatory3608 - School of Dentistry Residential Apt.3611 - Riverton Medical Center3612 - Hinckley Institute Apartments3614 - Red Zone - Sandy UofU Book Store3616 - Richfield Data Center3617 - AirMed Landing Pad and Staff Lounge3619 - Red Zone - Layton Hills Convenience Center3621 - Wall Mansion3622 - Red Zone - West Jordan UofU3625 - Willard L Eccles Observatory Support Building3650 - TARA Radar Transmitter Bldg - Lee Ditch Rd3651 - Central Laser Facility (CLF) Site3652 - Air Med China Ridge Bldg and Tower3653 - AirMed Residential Lease Nephi3654 - AirMed residential lease 3214 Dewar Dr3655 - AirMed residential lease 3218 Dewar Dr3656 - UUHC AirMed Layton3661 - Rio Mesa Center West End Tuff Shed3662 - Rio Mesa Center Bath House3663 - Rio Mesa Center East End Tuff Shed3664 - Rio Mesa Center Yurt3665 - Rio Mesa Center East End Shade Structure3701 - South Jordan Health Center3702 - Patient Appartments at the Baymont Hotel3714 - Moran Eye Clinic Farmington3715 - UUHS Community Clinics Farmington3716 - Reserved for the NEW Farmington Health Center3717 - Summit Center Business Park Occupational Therapy3720 - IHC South Pavilion3721 - OB - GYN Murray3735 - Observatory Control Building3736 - Huntsman Cancer Hospital Apartments3737 - David Eccles School of Business - Low Income Tax Clinic3738 - University Neighborhood Partners Hartland3739 - Emigrant Pass Building3760 - Range Creek Bunkhouse3761 - Range Creek Cabin 1 Room3762 - Range Creek Chicken Coop3763 - Range Creek Corrugated SIlos3764 - Range Creek Log Cabin 2 Rooms3765 - Range Creek Pole Barn3766 - Range Creek Pump House3767 - Range Creek Ranch House3768 - Range Creek Creek Shed3775 - Reserved for Farmington Land Purchase Building3851 - Environmental Humanities Education Center Visitor Center3852 - Environmental Humanities Education Center Shambow House3853 - Environmental Humanities Education Center Classroom Building3854 - Environmental Humanities Education Center Artist Residence3855 - Environmental Humanities Education Center Art Studio3856 - Environmental Humanities Education Center Maintenance Staff Housing3857 - Environmental Humanities Education Center Big/Little Sheep Cabin3862 - Environmental Humanities Education Center Student Dormitory & Apartment3863 - Environmental Humanities Education Center Caretaker Residence & Shop3864 - Environmental Humanities Education Center Dining Hall & Event Center3865 - Environmental Humanities Education Center Woodworking Shop3866 - Environmental Humanities Education Center Storage Building3867 - Environmental Humanities Education Center Guest Cabins3868 - Environmental Humanities Education Montgomery House4580 - KUER Communications Facilities - multiple sites4581 - KUED Communication Facilities - multiple sites4582 - UIT Communication - multiple sites9000 - Incheon Global Campus Academic Building A9001 - Incheon Global Campus Academic Building B9002 - Incheon Global Campus Academic Building C9950 - Structures that are not buildings9960 - Property not in a U building9970 - Shell number for temporary or mobile structures General Is flooring in good condition and free from trip hazards including uneven surfaces? * Yes No N/A Please include specific details below * Are floors kept dry? * Yes No N/A Please include specific details below * Are aisles and corridors free of obstructions? * Yes No N/A Please include specific details below * Are exits free of obstructions? * Yes No N/A Please include specific details below * Is the building parking lot area and surrounding sidewalks free of trip and fall hazards, including uneven surfaces? * Yes No N/A Please include specific details below * Are exits marked with an illuminated exit sign? * Yes No N/A Please include specific details below * Is the immediate perimeter free from dry grasses, weeds or other combustible materials? * Yes No N/A Please include specific details below * Is lighting adequate and functioning properly in all common areas? * Yes No N/A Please include specific details below * Are bookshelves, cabinets or other items over 4 feet tall secured to prevent tipping? * Yes No N/A Please include specific details below * Are materials on shelves above chest level properly secured? No overhead storage of heavy items. * Yes No N/A Please include specific details below * Is the building free of missing ceiling tiles? * Yes No N/A Please include specific details below * Are stairwells kept clear and not used for storage? * Yes No N/A Please include specific details below * Inspect building AED’s per maintenance check procedure * Yes No N/A Please include specific details below * Electrical Safety Are electrical receptacles located within 6 feet of a sink or in a wet and damp area protected by ground fault circuit interrupter (GFCI) outlets? * Yes No N/A Please include specific details below * Is the area free from cords routed across walkways or through walls or ceilings? * Yes No N/A Please include specific details below * Are extension cords used only temporarily? * Yes No N/A Please include specific details below * Are outlet covers in place on all outlets? * Yes No N/A Please include specific details below * Are plugs and cords in good condition? (no exposed conductors or broken insulation) * Yes No N/A Please include specific details below * Is a 36” clearance maintained in front of electrical panels? * Yes No N/A Please include specific details below * Fire Protection Have fire extinguishers been inspected and "date tagged" within the last 12 months? * Yes No N/A Please include specific details below * Are fire alarms and extinguishers visible and not obstructed by outside objects? * Yes No N/A Please include specific details below * Are fire extinguishers mounted properly and readily accessible for use? * Yes No N/A Please include specific details below * Is storage material properly stored 18" below fire sprinkler systems? * Yes No N/A Please include specific details below * Is combustible trash material properly stored away from heat sources? * Yes No N/A Please include specific details below * Is there adequate signage to indicate no smoking within 25 feet of building entrance? * Yes No N/A Please include specific details below * General Housekeeping Are all exterior waste dumpsters or containers with an individual capacity of 1.5 cubic yards (40.5) cubic feet) or greater, located at least 20 feet from combustible buildings or wall openings? * Yes No N/A Please include specific details below * Are all waste materials placed in the proper waste containers and emptied regularly? * Yes No N/A Please include specific details below * Captcha If you are human, leave this field blank. 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