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The undersigned special inspector or qualified agent of the testing <br /> laboratory, who has been approved by this department, agrees to <br /> comply with the above-listed duties and responsibilities of the <br /> special inspector. <br /> A <br /> INSPECTOR OR AGENT'S IVAME (PRINT OR TYPE) <br /> Z4 Ile -Z 11O3 <br /> INSPECTOR OR AGENT'S SIGNATURE DA E <br /> The undersigned owner or contractor will assume the responsibility <br /> of scheduling and notifying the testing laboratory of the above- <br /> marked inspections. The undersigned, also states that he <br /> understands the duties and responsibilities of the special <br /> inspector. <br /> i <br /> OWNER OR CONTRACTOR'S NAME (PRINT OR TYPE) <br /> OWNER OR CON RACTOR' SIGNATURE DATE <br /> SIA.DOC <br /> - 7 - <br />