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fov C rV [Fir ardu �, D U��Gog Gni on r filedinudnig Bev "Bee <br /> Recgiestwed So ice Agency Lecatrion of Device <br /> * Name n Company <br /> Name <br /> *Address � D vC�17r N �� *Address <br /> * i t''' <br /> Ci ty �- - op <br /> State , Zip cj p. , pvl,� Nfiv /� tate , Zip <br /> Phone ( � ) *County <br /> * Agent * Date of <br /> Name Ssr✓ ri�� <br /> Repair or <br /> Placing <br /> License # 31560 into <br /> Service <br /> Device Information <br /> * Device *NTEP CC <br /> ID * Device * Model *Serial Number Type of Device <br /> (i. e., pump Manufacturer Number Number (device or (capacity if applicable) <br /> or check <br /> stand #) component) <br /> 1715 <br /> CAI L:61kvk4u 27 C7 <br /> Remarks . <br /> S Tb .7 L S 1- 0 , C.A i 10 <br /> gel all = <br /> " REQUIRED INFORMATION Reference: California Code of Regulations, Title 4, Division 9, Chapter 4, Section 4085 (a)(2) <br /> Link to county contact information: <br /> http ://www , cdfa . ca . gov/exec/county/documents/countycommissionersealercontactinfo . pdf <br /> � a, <br />