elickY‘e 0 us V--) 0 2-0 k 000 4 10 1",

MOBITEL
1 of 10
BTS PAT Document

2012-09-21_V1
0 & M Manager BTS: Ramesh Sanjaya

Preliminary inspection
BTS installation

INSPECTION DATE: 9..6 (el )0-6 )

SITE ID: ?Ok1\01_

SITE NAME: o'NvsA

SITE ADDRESS: 9. 6,1 5; G'or o‘ 5 ...,Ack,40A-)Nw,k ,DiGlO OLJe1 jVV'

0,(AA vd I 6\ e

BTS Type:

BTS CONFIGURATION *2_ 4. .2_ -It_ -2.kit no)) 2 -"sr (

FREQUENCY BAND: E60 MHz D4800 MHz 0 3G DLTE

PAT Type: 0 New BTS 0 SWAP 0 DB conversion0 Band conversion

o co3--;()
RU/RRU Type Ki60 giucibq ) R-R.0 Itaoo
Battery Capacity rrYi s 0 AV* q:5 6„..1 0 p e-ck-e)

PAT Status:
• Pass
• Pass with Minor El
• Reject El

Remarks:

Major - Affects human safety, equipment safety Service quality and long term operations.
Minor - Does not affect human safety, and/or equipment.
 MOBITEL
2 of 10
BTS PAT Document
itel
2012-09-21 V1
0 & M Manager BTS: Ramesh Sanjaya
Major
ot
or OK Comment
NOK
Minor

1.00
Earthing

Feeder cable earth connected to ECB at

1.11 Major tv,
90 bend, within lm (Vertical rise)
Feeder cable earth within 1M from bottom feeder
1.12 Ma or t/'
connector
If vertical Feeder length >30m additional Feeder
1.13
cable earth connected to ECB at every 30 m level
Major „_
Feeder cable earth within 1M from top feeder
1.14 Maj or \/
connector
If Horizontal Feeder length >20m additional Feeder
1.15 cable earth connected to ECB at every 20 m Major
distance
1.16 TMA Earthing through proper clamping on tower Major —

1.17 Feeder earth kit sealing with self bonding tape Major V"

All GI Pipes earthed from one side (with nut & bolt)
1.18 Usually it must be from BTS end to the busbar at the Major —
side of the plinth.
BTS Cabinet earthed (From Cabinet to Busbar,
1.19 25mm2 cable lug with washers it must be to bus bar Major V
at the side of the plinth [Single Line ECB].
1.20 AC Power Cable shield should earth Major ./
Patch pannel and power distribution box (ACPDB)
1.21 Major ,/
earthing to main ECB
Surge box (SPD — if available separately) earthing .
122 Major j
cable to near Bus bar.
SPD pole (if mount to plinth) should earth by
1 .23 35mm 2 Cu cable
Major ../
SPD pole (if separate) should earth by
124 Major .1
Cu tape
1.25 Steel Plinth earthed by nut & Bolt Major ---

1.26 Horizontal Outdoor cable ladder should earth Major --/

Outdoor cable ladder support should earth using Cu
1.27 tape, Support pole need to be connected by nut & Major V
bolt.
Tower ECBs are properly Earthed using 35mm 2 z
1.28 Major v
Earth Cable

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
3 of 10
BTS PAT Document
iobi et
2012-09-21 V1
0 & M Manager BTS: Ramesh Sanjaya

2.00 Hardware Installation

Cabinet(s) bolted to plinth correctly with washers.

2.01 Major
Use 04 bolts & it must be GI. V

2.02 No obstruction at BTS fan & Door filters cleaned Major ./

2.03 Cabinet Door Can Open And Close Easily Major ‘,/

2.04 Cabinet Door Locks And Unlocks Easily Minor ,v

2.05 Power supply system has been properly secured to Major ,,/
the floor or plinth
2.06 Batteries have been properly installed Major
No of batteries installed: '6'
2.07 Battery system has been properly mounted Major ‘/
Battery type &capacity•fT- a - 150
2.08 No external Damages in cabinets Major v
Fastening of units inside the cabinet(BBU, sensors
2.10 Major N/
etc..)
Cable inlets and outlets are properly sealed in order
2.11 to be protected from water, humidity, dust, rodents, Major
insects
3.00 Cabling

3.01 Proper cable routing. Minor V

3.02 Power and signalling cables are separated. Minor V

Feeder Cable Routing (jumper cable is less than 3m
cable with drip loop, in case of more than 3m prior
3.03 Major V
approval shall obtain at TSSR/Readymade jumper
cable must use).
Connection of RF cables to RU is properly
3.04 Major \,7
Secured
DC power cable from the BTS cabinet to the
3.05 rectifier (+) busbar and (-) busbar are installed Minor j
correctly
AC power cable from rectifier to the ACDB is
3.06 Major \i
installed properly
Proper Installation of fibre cable from BTS to
antenna (Each fibre cable is separately secured
using PVC/Fibre clamps are fixed at 2m interval, -\/
3.07 Major
Top & Bottom of PVC end are sealed properly ,
bending and tower top fibre cable are secured with
GI coated flexible PVC)

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
4 of 10
BTS PAT Document
,ob ef-
2012-09-21_V1
0 & M Manager BTS: Ramesh Sanjaya

The El cable is connected at the BBU to the Tx

3.08 devices properly(For Node B, 8E1 cable must lay Major \/
and connect to the BBU)
Alarm cables for sensors and alarm panel are
3.09 Major v
installed properly
3.10 All Cables are Labelled Major V
Electrical wiring neatness
3.11 (Proper securing with Buried GI & GI coated Minor V
flexible PVC)
Using proper colour code & approved cables for
power connection(Including load cable, Indoor &
outdoor)
3.12 Major V
Recommendation:
Ll,L2 & L3 colour- Brown, Black, Grey
N colour - Blue
AC Power cables laying over the plinth should be
3.13 Major V
in 1.5 Inch PVC coated GI flexible
DC Power cables laying over the plinth should be
3.14 Minor V
in 1 Inch PVC coated GI flexible
Physically check the El from TX devices to the
3.15 Major
BTS
3.16 Use two colour code for DC cable Minor V
The FE cable is connected at the BBU to the Tx
3.17 devices properly and secured with GI pipe Major J
(Applicable for NodeB)
The Fiber cable is connected at the BBU to the Tx
3.18 devices properly and secured with GI Major —
pipe(Applicable for eNodeB)
All FE/E1 cable should connect to relevant surge
3.19 Major .v.
protecting board at the BBU
4.00 Antenna and feeders

7/55 o\v‘.1 4 ih e--1

4.01 Feeder Type ( Size 7/8 , 1 1/4 or Fiber) Major ,V"

FeAe -N, - -1-5 ‘"''. )( t

4.02 Feeder / Fiber Length Minor -
4 1‘

YA
Sector A.
1 ,- h
N./
4.03 Top Jumper Type Minor Sector B
1 , i,
Sector C Y"2,

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
5 of 10
BTS PAT Document
„ob el
2012-09-21_V1
0 & M Manager BTS: Ramesh Sanjaya

1
Sector A P2

4.04 Bottom Jumper Type Minor V Sector B /1.

a
Sector C )42,—

Sector A 3
,../
4.05 Top Jumper Length Minor Sector B 3

Sector C 3'

Sector A 3 w,

4.06 Bottom Jumper Length Minor .1 /4/ Sector B 17*".'

-' ie-
ct
Sector C

Sector A 11 `

4.07 Feeder clamping (Distance < 1.5m) Minor / Sector B I''''

Sector C I '

Sector A t X '

4.08 Fiber clamping (Distance < 2m) Minor ✓ Sector B If I'vl

2-

Sector C ‘.A- I''‘

Sector A %...--

4.09 Feeder / Fiber labelling Major .., Sector B ,..,-

Sector C
Sector A 1 t. -•
Sector A2
Sector B1 Iv
4.10 Feeder / Fiber inlet & other openings are sealed Minor \/
Sector B2 V
v
Sector Cl
ii
Sector C2
T41 b ,,,,, 4 )( 3

4.11 Antenna Type & model (manufacture code no.) Major

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
6 of 10
BTS PAT Document
,obi et-
2012-09-21_\/1
0 & M Manager BTS: Ramesh Sanjaya

-Sector A 2, E e? M
Antenna down tilt (measure through digital tilt
4.12 Major V Sector B 9- E ° M
meter)
Sector C 9" E t) M
Sector A t,

4.13 Antenna in correct tower leg Major t.7 Sector B t' .

Sector C 1.
Sector A
4.14 Antenna in correct height Major „/ Sector B
Sector C
Sector A 30 ,.
Antenna directions (As according to Mobitel
4.15 Major v Sector B 61, 0
Information/Measure through cell alignment tool)
Sector C 2;)5.- '
Sector A ''
Feeder / Fiber & Jumper connector properly 1.---
4.16 Major \./ Sector B
Sealed t.,
Sector C
VSWR 12-9— llIVIT / m 143° 6
Sector Al I ' °3 / 1 '7-3 1 .1 0
VSWR Test (<1.4) Sector A2 ..1.,.P.5.1/:`:2 °. . ...I !' ! ;'..
4.17 DTF Test (<1.05) Major y,/ Sector B1 1'671)..1. 1,1,0.
Sector B2 .1.1.0.-tht-i.i.... ... I- . ‘: ...
Sector Cl 1' 60 1* 7 I , 1 P.
Sector C2 .1, li11.k.15. „A.,. . 1 . A.
Sector A t.--
(..---
4.18 Antenna pole must be vertical. Major \-/ Sector B
V
Sector C

4.19 Ability to reach the antennas for O&M works Major 1,-

5.00 External Alarm Test

5.01 Intruder Alarm Major v

Smoke Detector Alarm (Applicable for Rectifier
5.02 Major ',7
cabinet only)
5.03 Temperature Alarm Major v
Water Leakage Alarm (Only applicable for battery
5.04 Major
and RF cabinets)
5.05 Main AC Fault Alarm Major ,Y
Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
7 of 10
BTS PAT Document
,ob e
2012-09-21...V1
0 & M Manager BTS: Ramesh Sanjaya

5.06 DC Under/Over voltage alarm Major

5.07 Battery Low Voltage Alarm Major

5.08 DC Under Voltage threshold (V) Minor

5.09 AC Under Voltage threshold (V) Minor

6.00 RU Power Output Test

6.01 RU output sector Al Major Watts

6.02 RU output sector A2 Major Watts

6.03 RU output sector B1 Major Watts

6.04 RU output sector B2 Major Watts

6.05 RU output sector Cl Major Watts

6.06 RU output sector C2 Major Watts

7.00 Call Test

7.01 Mobile to Mobile Major v"

7.02 Mobile to Other Major v,

7.03 GPRS Testing Major 'fr .

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 ......„, ...... MOBITEL
8 of 10
BTS PAT Document
.

0 & M Manager BTS: Ramesh Sanjaya

8.00 RF Cable diagram for RU

RU RU RU RU RU RU

9.00 BTS Inventory & Serial Number

9.01 BTS Cabinet S/N alt7 066 9-4C1 /3

9.02 RU CO3) 'iv.e_A- r0°,4 S/N --1 0 0 60 —1 1 4'70

9.03 Jkii- 6 6 c ci\ww,th S/N 2st..1.de,b3 0 cl

9.04 RU t,bE 61 ulos S/N 2-1 CIO V)I '2. 7SS

9.05 RU6A.) 90%. S/N 2_196 31 22 1 9 ''

9.06 RU tica6l ucioq S/N '2_19b41--ic517

9.07 RU S/N

9.08 BBU 4.20o S/N _2,1.0 0 0 6 0-3 —) 0 2._.

9.09 CC S/N
Cc C
9.10 FS (_..F, b ) S/N 2,5 ss- S hob 1 CPS

9.11 UBPG S/N

9.12 .4,11E
3 uM)61 S/N 211S 1, 33 60 I I '
—
9.13 BPL S/N

9.14 RRU SN c2-1 ci b 6 -76 '? ) 93

qig 2 ()too )

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
9 of 10
BTS PAT Document
',,obite -
2012-09-21 V1
0 & M Manager BTS: Ramesh Sanjaya

9.15 RRU 2_ (Ige),, ) s/N ) 9 b 361 0 1'2- 3 6

9.16 RRU f3 e6c6 2_ Co. 00 ) S/N alcio-ci 56 65 q

9.17 RRU S/N

9.18 RRU S/N

9.19 RRU S/N

S/N 21 Oa S 7 6 6 b..g..*...47
9.20 SMR (z 1)2+0 o) S/N 21 VD 46 $9,--9S 34
S/N ...2.-.1.0.0.6. S./ .77. •364.1
9.21 SA S/N 2-7 i. ;.S a 0'6 .0 2—

St-ixo SitA el-1 boS°1 '2-S 91 oo

10.00 Miscellaneous
Black UV-resistant ties used for outdoor
10.01 Minor v
cable fastening
10.02 Site is clean Minor Iv
Retain the additional engineering material for
10.03 Minor — Bonding tapes, Insulation tapes, etc
future use

11.00 Material Quantity Confirmation

Item
No Description Qty Brand Capacity/Specification
11.01 SPD
o I ^te---‘o,,, el cf-to,-, p 0 kit- U 1
11.02 ACPDB (3 phase)
o) N.e.---oveA.. c^lil"..., poiLh-u )
11.03 Meter Cubical

11.04 40A / 4P breaker at Meter —

Cubical

11.05 4 X 16mm2
CU/XLPE/SWA/PVC
cable(M)
11.06 4 x 6mm2
_
CU/XLPE/SWA/PVC
cable(M)

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 MOBITEL
10 of 10
BTS PAT Document
',obite
2012-09-21 yl
0 & M Manager BTS: Ramesh Sanjaya

11.07 GI plinth
,-,
11.08 GI pipe length —
11.09 Additional Cabinets

11.10 SPD Pole 0)

11.11 Feeder Earth Kits ( 'K
11.12
Feeder/Fiber length f9--e-A--1 45 M .-A ''' V'ib e--1 f••0 qi-,.• )( 3
11.13
Feeder Clamp If 0
11.14
TMA
11.15 e, 3
Cellular Antenna le,,e....4 44-,--._ V o VA u)
11.16
MW Antenna Brackets
11.17 c-,) 3
GSM antenna brackets 6y c \ J;
11.18
Batteries 0 (16 lit)? re—C. k..e,, yes,--ova. p'., ? 0 kA v )

BTS check list shall be verified and attached with this document.

Preliminary Acceptance Test for BTS installation has passed.

Following conditions will check before issuing the PAC other than the contractual PAC obligations.
• The values of VSWR& DTF are between 1.3-1.4& 1.04-1.05, then re-test will be performed
by Mobitel after the 3 months of period and if the values are further increased
Sub-Contractor responsible to clear out any issues related to VSWR & DTF at that time.
+ External Alarm Test should according the finaliztion monitoring solution.
+ TMA functionality shall be perform with the drive test and Sub-contractor is responsible to
rectify if such issues noticed.

Site ID: pa
Site Name: K---0\UAAJA\ c/ 2_
BTS Type: Sot ei
Frequency Band: 0 )

Date: S i ('Y

For Mobi 1 Regional Operations For Projects For Sub Contractor

Name: Name: Name: 1_

Major — Affects human safety, equipment safety Service quality and long term operations.
Minor — Does not affect human safety, and/or equipment.
 Sri Lanka
Te scorn
Direct Implementation Project - Equipments Inventory

Removal (R ) New installation( N )

Date 201 9 Iti 6 ) to
Site ID Po l--Ru
/--/.
Site Name„,,,, Wc.k0A,,k‘l C 2
Region vt))0vwx,,,ykAk--,0

Collected From Installed At / Returned to

Item Serial number
WH Site ID WH Site ID
Shelter removal(Yes/No)
Cabineti 000 40-ci 54 g q s• — 11°14-Pt-kJ .1 .
RF Cabinet fk--)14 Pt01_
Cabinet2 IA 0.060 51/4_70 — 4® - Fk \J i - Po 1L-A V 2-
Cabinet1 29/ boo 3, co_ ,4 ----
Power Cabinet 4” — Po KA U ) t9 014. PN 2_
Cabinet2 —

R0420e: PAti/MRFUI. 2.[gbill...g '7435 — Pol4-A k) t — [9014-1; VL.

_ __
RRti/MRFU2 2190 3)2_2 ; i 9- Po (LPN i Po VP% U 2
RRfl/MRFU3 — Pok-Au 2_
2_1 <106 1-- ) fi-7 t 1 PO V-Itkil 1
f3Rti/MRFU 900
RRU/MRFU4
RRU/MRFU5
_
RRU/MRFU6
_ _
RRU/14RFCn 9-1 61 0301 b 7)13 VoVAu i Poo-14V'2.
21 go '910 72 34 _ -----
RRU/IviR,FW-2 Po --Isi u i VoI4AV 2
____ --
RRU/URFU 1800
RRU/URR-13 ea-lq b 2 q 56 4 5 3 s v0 v--.1) k..) i Pole:Pt U-
RRU/MRFU4
RRU/MRFU5 —
—
RRU/MRFU6
_ _
BBU1 52" 21 Cab C.0376 13 2_ 190 14--Pkv) c76 12-A 0 I
BBU
_
BBU2
—
CC1 ECG 2,) 2_5 4--; 9 q 2-6° i 35 904- AU ) Qc.)14-AU 2_
CC
CC2
_ ____
FS1 (f-Ø0) 2_5,
3 5)00 + 0a voiLA u 1 po14-Au 2
FS
FS2
_ go v_Au i _ pc, \4_ Au ,
UBPG
UBPG1 2-11t.“ t-, 15 n
UBPG2 2-7 )“3 9) C)6 II ,- pokiPtUi — Coli-Av 2
BPC BPC1 .-----
_
BPC2
BPL BPL1 —
BPL2

Item Removal Inventory Page 1 of 3

 iSri Lanka
Telecom
Direct Implementation Project - Equipments Inventory
We Care, .4,4a-vs.

GTMU1 Z
GTMU
GTMU2 7
WBBP1
WBBP
W
DTMU DTMU1
Collected From Installed At/Returned to
Item Serial number
WH Site ID WH Site ID
DDPU1
DDPU2
DPU2
DDPU3 /
DDPU 900
DDPU4
DDPU5
DDPU6 /
DDPU1 /
DDPU2 /7
DDPU3
DDPU 1800
DDPU4
D
DDPU6
BBU 3806
WRFU
PSU -%(1)140b 9-160.530-6 0.3 4-4-
_
1‘14)N4Fati 117 5 ( 9 z>tD24--oo f2---1 to 0 6 b 2-i 5 3 -4 Po A k.,11$ Po'VA.V2_
.....
Other- ?.S c z_7(1) 2._4_00 '2_} a o 5 Set 73 -6 9 Poy-Av ) - Foy. flo -
,-.. ¶2o
(54 m u 2_100 51 zsci 16 0 Vo PIA) 1 - o Y--- AV1
_ _
?It LI 'CO'Or 2ç o o c,6-1 4-14614 Po V-A 1) i Po KAk.)-z_
_
9-7 2- is ci 360 6 2-6
k 2113 ci 00S-4 2,.._
- Po k
9) CJI
T 1VA '2_100 66 eO 2 56) 1 Zi
—
9.- fikINI 5 2-‘9 0 3)22q 4 OC) YA u)
PC) - 9o4riv-i_
-
Pokilu, Qbizt4 0 ,
.fee--t

Item Removal Inventory Page 2 of 3

 Sri Lanka
Te ecm
o

Direct Implementation Project - Equipments Inventory

We Care, Mways,

Remarks

Reginal Officer Site Engineer - Project Sub Contractor

Removal Name

,--v
Signature
/'---
Date 7*-. ----7------"''''

New installation Name f j T ....,,:‘,„„,_,....._

cm n et
Signature Ap,./....—__ ''''.N
------- --
Date
/ id" /9 (,( 9 2kci 0 ii% '2,-,-= v 62 /4 1 p)

Item Removal Inventory Page 3 of 3

 T e gcI L6M
Direct Implementation Project - Equipments Inventory
$ Carr. niIsi

Removal ( R ) New installation( N)

/
Date ae lq luG 11)
Site ID 9 0-ku
14 N
Site Name
Region pa lovw
______‘,‘
,J

Collected From Installed At / Returned to

Item Serial number
WH Site ID WH Site ID
Shelter removal(Yes/No)
Cabinetl 2Aooto ci sCGcos .- _
RF Cabinet itot4_A-ty t ?0 1,
--Av 2-
Cabinet2 .2 t,o‘Oco 7 lif7 b — POte-nt) 1 r-'• ?O;L
Cabinet1 29100030q/s 4- — ?c)K. et u
Power Cabinet Po ‘e-PN )
Cabinet2 ._

RM/MRFU1 21go "7 5 - 1/6K AU i Vo ILAN) q_

-
,RRCJ/MRFU2 '2.1 q 631 ir2- 31 13 ,---
P.:Iktr/MRFU3 Q.. MD
FRO/MRFU 900
RRU/MRFU4
-
RRU/MRFU5
RRU/MRFU6
RRU/1\j.RFU1 -21 ct. 30-70 -ii 1 3 , PorAU, - 90 V-AV-7
RRU/VIRF-tr2 21 ei 03 0 `76 '7 73
RRU/MRFt13 _.1 q Se) 45 3 4s - Voiz-Av L - ?c) KAU,
RRU/11RFU 1800
RRU/MRFU4
RRU/MRFU5
,
RRU/MRFU6
BBU1 °° 9.4 vo 66 S-761% 2 - ,i7C*-iit)i —•
BBU
BBU2 -
CC1 (C.0 2- si- '9 99.._06 et s5 - _
CC kti-AUI ?0KAUD
CC2 ....

FS1 fS c-,,) '2.5 c3cs St i Of) ICA ,--- •-

FS pc* AN b Po )411 U-2_
FS2
UBPG1 ."71 .sg.ML,I5 c-7 - fo-INV) - Pole-AU,
UBPG
UBPG2 2-1 It`336611cs - pok Au ) - po v-At,42_
BPC BPC1 c-
BPC2
BPL BPL1 -
BPL2 —

Item Removal Inventory Page 1 of 3

T ecLert
r il
Direct Implementation Project - Equipments Inventory
WO CVO: 410,11) 5

GTMU1
GTMU
GTMU2
WBBP1
WBBP
WBBP2
DTMU DTMU1 ,

Collected From Installed At/Returned to

Item Serial number
WH Site ID WH Site ID
DDPU1
DDPU2
DDPU3
DDPU 900
DDPU4
DDPU5
DDPU6
DDPU1
DDPU2
DDPU3 _
DDPU 1800
DDPU4
DDPU5
DDPU6
BBU 3806
WRFU
PSU '2--•7(1 ifoo — --
9-1 0 0 5 76 4 C? 3 4- 1.- Pol<- A v ) Vc,k-il) 2._
MW- Dti pso :, 2400 21i> o C, v S2._ q S 3 4 _
4
P ok-Au
Other _
Pc-A) zArD-4-oo '21 o 0 S 5 '17 3 5 -6 1 Q0. AV
— _
S MA) '216059 2-Sfctlt70 POY- A U i PC*140-2
FAN 1,1,,,i v_)00 607‘flz)-9 i4- —
1;' rft 3 '2 3 21 (1 30 0 0 2 O - PO /4.
?c, kAv 1
"Dc7D4P(- .2.1,0 .6 0S2 .5q 7-4 — F04 A 1/4) i
-
fO)CAU-L,

_
-
—
fo t4_ fk1/2._
f- 5 2120 ( 5 2_ 60 91 ) Po VAo,

Item Removal Inventory Page 2 of 3

 TelVali
Direct Implementation Project - Equipments Inventory

Remarks
*e-e_ci k• ""Y -7/c s
s s
R1Z-Q ce,b) e s
cryw, ')Z 3 9-12A) ?t,

Regina! Officer Site Engineer - Project Sub Contractor

Removal Name
, , stiol Dv,----, L ,,,, A 1-i
Signature .......

Date
I / 0 E/1(er .aok el 166 it <-2-.° Vi 10.6'. 1 i 3
New installation Name .,--

Signature

Date

Item Removal Inventory Page 3 of 3