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CUSTOMER NO: <br />EAS! PENN manufacturing ca. inc. <br />LYON STATION, PA 19536 <br />Repair & Adjustment Form <br />DATE TRUCK RCT FROM (LOCATION #): <br />DRIVER: ADDRESS: <br />RA <br />TAG <br />NO. <br />TYPE <br />BATT. <br />DATE <br />CODE <br />BRAND <br />REASON FOR <br />ADJUSTMENT <br />PURCHASE <br />DATE <br />CLAIM <br />DATE <br />MTHS.IN <br />SERVICE <br />CREDIT <br />UZ <br />TOTAL QUANTITY <br />H.M. <br />DESCRIPTION <br />TOTAL WEIGHT <br />BATTERY WET, FILLED WITH ACID, 8 <br />UN2794 PG III <br />EMERGENCY CONTACT: 1-800-424-9300 or 703-527-3887 <br />TOLL-FREE IN US, USVI & CANADA ELSEWHERE <br />This is to certify that the above named materials <br />are properly classified, described, packaged, <br />marked and labeled, and are in proper condition <br />for transportation according to the applicable <br />regulations of the Department of Transportation. Certification Signature: <br />White: EPM Main Office Copy Yellow: Customer Copy <br />E.P.M. Form No. 0417 Rev. 4/06 <br />Pink: EPM Transportation Office Copy <br />© 2006 by EPM Printed in U.S.A. <br />