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Elite IV Contractors <br />2535 Wigwam Dr. <br />Stockton, CA. 95205 <br />0 PLACE IN SERVICE NOTICE <br />• <br />Phone: (209) 461-6337 <br />Fax: (209) 461-6342 <br />P.O.# f Work Order# ------- ___ <br />ENOTICE OF SALE, LEASE, LOAN <br />County Date Service Agency Registration No. <br />f f 2278 <br />LOCATION OF DEVICE <br />Name of Customer Address City Zip <br />WEIGHING OR MEASURING DEVICES PLACED IN SERVICE <br />Manufacturer <br />Model Number <br />Serial Number <br />Device Type <br />Cert. of Conf. No. <br />(if device is new <br />and marked) <br />Capacity <br />Out of Order <br />Tag Number <br />Device <br />Location <br />Remarks: <br />Tags enclosed if applicable <br />❑ Yes ❑ No (if no explain in remarks) <br />Date placed in service <br />/ f <br />Date this notice was: El Mailed <br />f f El Faxed <br />Print Name of Service Agent <br />Signature of Service Agent <br />Service Agent's License No. <br />