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Ame Location Address Contact Name Contact Telephone Number Regulated Vessel Information Type Of Object Manufacturer Serial # or NB # Please Leave These Columns Blank They Are for BPV Div. Use Only Indiana Reg. # Cert. Exp Date For Code violations, or adverse conditions, use reverse or attach additional sheets or reports. Year Built Loc. in Plant This ' Request for First Inspection' form cannot be used to Notify the BPV Division of New, Cancelled or Suspended insurance risks, as refere.

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