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Etarded LARGE 1. (A) PROVIDER NO. Form Approved OMB Exempt 1. (B) MEDICAID I.D. NO. K1 K2 PART I — Figure 6.8 — A Procedure for Determining Evacuation Capability PART II — Chapters 32 & 33 — Residential Board & Care Occupancies — Requirements PART III — Figure 7.5 — Fire Safety Evaluation System for Board & Care (Optional) — CMS-2786T Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (A) MULTIPLE CO.

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