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0ca cod Hcy=d So MHco R `parLr <br /> > cr �� friri1crir�iU�Cl << V��IocojG� o1Cow6v� c-mm �a �° o �� c � Dc� � � c� �� s <br /> R)ogucstered Service Ageowy Location of Devuce <br /> * Name *Company <br /> NameLfc) PLAV<�4 i <br /> *Address 20 c� Ut . c` fJ L/ C( *Address <br /> *City, *City t> G � <br /> State , Zip P--cV2 4 1rkeot b (&, State , Zip <br /> Phone ( � 16 ) �Qr ,4 0 2 *County Sam <br /> \,y t= a <br /> *Agent � * Date of <br /> Name FSS� ell <br /> Repair or <br /> Placing <br /> License # 3 ` 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 /> orcheck <br /> stand #) component) <br /> Remarks : <br /> ` REQUIRED INFORMATION Reference: California Code of Regulations, Title 4, Division 9, chapter 4, Section 40 (a)(2) <br /> Link to county contact information. <br /> http ://www. cdfa . ca . gov/exec/county/documents/countycommissionersealercontactinfo odf <br />