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2010-09-15 15:43 Costco #1.031 <br />Elite IV Contractors <br />2535 Wigwams Dr. <br />Stockton, CA. 95205 <br />PLACE IN SERVICE NO'T'ICE <br />2098258204 » 2094683433 P 16/17 <br />46 <br />Phone: (209) 461-6337 <br />Fax: (209) 461-6342 <br />P O.# / Mork Order# <br />NOTICE OF SALE, LEASE, LOAN <br />County Date Service Agency Registration No. <br />f 2278 <br />LOCATION OF DEVICE <br />Name of Customer Address City Zip <br />WEIGHING OR MEASURING DEVICES PLACED IN SERVICE <br />Cert, of Conf. Na. <br />Manufacturer Model Number Serial Number Device Type (if device is new Capacity Out of Order Device <br />and marked} Tag Number Location <br />Remarks: <br />Tags enclosed if applicable Date placed in service <br />Q Yes C3 No (if no explain in remarks) f Date dais notice was: Q Mailed <br />E3 Faxed <br />Print Name of Service Agent Signature of Service Agent Service Agent's License No. <br />