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em c�c� c� G� c�� r��� <br /> fair Corm Lroardfla i1n, Up] Mg aw <br /> Registered Sehvice Agenc 09 Device <br /> * Name *Company <br /> ojorj \ tkc. 1✓ tJ Name 10 � � b �N y <br /> *Address <br /> So � c. i� C ►J Lim c7 C *Address <br /> 'City, *City � p�`"TL � A 95 33� <br /> State, Zip PCC �� � 1� State, Zip <br /> Phone ( 011& ) 2'6 r �- C� *County R` � \ <br /> I �V PrQ t ) 1 N <br /> *Agent *Date of <br /> Name Repair or <br /> Placing Zo <br /> I�ur ense # 3 i into <br /> Service <br /> Device information <br /> *Device * MTEP c c <br /> ID *Device Mod di 'Serial Mumber Type oV Device <br /> i.e., pump Manufactwer lumber Number (device or (capacHY If Sappft,9ble) <br /> or check component) <br /> stand ,1 <br /> C^ , Lt3 v 3 VV 313 7 q q 52 - O ! CnAS7: 3rt� <br /> #� Z (-, t L Q n�co <br /> 6, t LTA , 3ocD 3ib' gv b2 - nth C"A' TunP <br /> i:t� 13 6 , + LfAvtc c 7 b 6 7 � 1? z� t) Q Z - 61 <br /> -i ) 5' L-- i 4, (3 pv�cg 300 ; d331 00 • vlei C-,kS ?Q h% P <br /> 1:17, l C, i L 9^ewtCZ3 u0 ' + U 2 Q Oi c7 L,(VS Pj <br /> 2i u3/stl� 3F 'N COINS per- <br /> H & S Energy, LLC <br /> 714-761 -5426 <br /> Registration # 3776 <br /> Jesus' (Jesse)Romero License # 31360 <br /> DATE . <br /> " REQUIRED INFORMATION Reference: califorr Fa Code of Regulations, TJtle 4, Division 9, Chapter 4, Sectlon 4085 (a)(2) <br /> mggc to ccuwycontact informatlons <br /> iitt :/ www.cdfa .ca. ovlexec/coun /documents/coup commissionerseaiercontactinfo , df <br />