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G� [1a cc,, o � � crr�� o � Repo <br /> U,0rr C rrir Irf . � ch-.1 �j�y(� oPJ �� "HrlaQ � V Misa 's g �r�� �=� � new ces <br /> Registered SerAce Agency Locati n aV Do- Ace <br /> *Name /� v l �. *Company t7d for-Jtn� N � -7 <br /> v o nj " tj rvLct) Name <br /> *Address *Address <br /> � v G� �c-`n �io Lc- P- c) cT l9 Z L �► '71-} 12c� i� � a'l� <br /> *City, *City <br /> State , Zip o. c_ n prl � N r � [� �, State , Zip <br /> Phone ( gl6p ) 2 ?I 5'0� L( O Z *County 5, <br /> 15 2 <br /> *Agent � *Date of <br /> Name °�i2SSc �"btF� Repair oir <br /> PBci " g <br /> License # On 0 <br /> 3 1 3 Service <br /> Device Information <br /> *Device 'IMTEPF GG <br /> B ® *Device *Modell *Serialufflfbeff Type of Devipe <br /> (L e., pump Number Number (device or (capacity If applicable) <br /> or check <br /> stand #) component) <br /> ) � 61103A� VLCO 30t,> � Z - c� 1 CJ <br /> 63etru arBma <br /> f <br /> elk <br /> ��� �} c3 <br /> 9 � � CA�c l o�� -�� a ° �� .� 7�S Owe <br /> * REQUIRED INFORMATION Reference: Califomla Code of Regulations, Title 4, DIv/sWrn 9, Chapter4, Section 4085 (a)(2) <br /> Link to' coungy conga, a Information. <br /> http : //w it facdfa. ca .gov/exec/county/documents/count commissionerseafercontactinfo pdf <br />