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SHAYY S MAINTENANCE, INC. <br />928 W. GLENWOOD RD. <br />PO BOX 3610 <br />TURLOCK, CA 95380 <br />PHONE: (209) 668-8436 <br />FAX: (209) 668-8495 <br />M PLACED IN SERVICE NOTICE <br />• <br />0 <br />NOTICE OF SALE, LEASE, LOAN — <br />County <br />Address <br />23q SerocKM. v.vs <br />of 53yv <br />City <br />Fi��ti �Ct <br />Date <br />�i�11v� <br />Service Agency Registration N <br />f3AN <br />Jia Ulm <br />Device <br />Location <br />07 -/o - til <br />I2O SU /°<5pp <br />R PCM - t o <br />0.3'3 <br />LOCATION OF DEVICE <br />Name Of Customer <br />�HDSE S�t(�(YLtS <br />Address <br />23q SerocKM. v.vs <br />of 53yv <br />City <br />Fi��ti �Ct <br />Zip <br />SJ�(o� <br />�i�11v� <br />(ZiQoN Cs{ <br />Capacity <br />Tag Number <br />WEIGHING OR MEASURING DEVICES PLACED IN SERVICE <br />Manufacturer <br />Model Number <br />Setial Number <br />Device Type <br />Cert. of Cont No. <br />(If device is new <br />and marked <br />Capacity <br />Tag Number <br />Device <br />Location <br />�1 r <br />1D TI'Ltt^" <br />I2O SU /°<5pp <br />R PCM - t o <br />i ) 3- tZ <br />i'jK&17 <br />ir7Kl{ti v" <br />f1 / <br />Remarks: p �VEI� NDN eOv UNE('SS\/, O{1�i-� do.) Cat'.-.eu <br />v-wi46 lock IV i.-e�DInj 6770a2f <br />Tags Enclosed if Applicable <br />❑ Yes [� No (if no explain in remarks) <br />Dale Placed In Service <br />07--10- 5 ( <br />Date this Notice was: Mailed <br />-) -11- O � � Faxed <br />Print Name of Service Agent <br />vt <br />Signature of Service Agent <br />Service Agent's License No. <br />SAN001(UV 6/01) <br />