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e <br /> Elite IV Contractors Phone: (209)461-6337 <br /> 2535 Wigwam Dr. Fax: (209)461-6342 <br /> Stockton, CA. 95205 P O.#/Work Order# <br /> PLACE IN SERVICE NOTICE D NOTICE OF SALE,LEASE,LOAN <br /> Comity Date r Service Agency Registration Na <br /> LOCATION 00 DEVICE <br /> Name of Customer Address City Zip <br /> WEIGHIl�TG OR ME <br /> A,SURING DEVICES PLACED IN SERVICE <br /> CerL of Manufacturer Model Number Serial Number Device Type (if devio u n woCapacIty Out of Order Devioe <br /> and muked) Tag Number London <br /> 1 <br /> i <br /> i <br /> i <br /> Remarks. j/�jam/{r j Aa `iM'/• ���//.r 1��� \ ��!/J�/ �J ��/y <br /> { <br /> Tags enclosed if applicable Date placed in service <br /> Dare this notice was: ailed ! <br /> 13 Yes ❑ No(if no explain in remarks) <br /> - 141qll"ll <br /> �'�b U ❑ Faxed <br /> Print Name of Service Agent ignaf gent Service Ageat's License No, <br />