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Elite IV Contractors <br />2535 Wigwam Dr. <br />Stockton, CA. 95205 <br />PLACE IN SERVICE NOTICE <br />County <br />Name of Customer <br />Cl �� /-A <br />C.•-- Phone: (209) 461-6337 <br />.JAN 112019 Fax: (209) 461-6342 <br />P.O.# / Work Order# <br />NOTICE OF SALE, LEASE, LOAN <br />Date Service Agency Registration No. <br />3"120 <br />LOCATION OF DEVICE Zip <br />Address City % <br />w 1-1 /G' L; <br />Remarks: <br />applicable Date placed in service Date this notice was: El Mailed <br />Tags enclosed if app � / <br />❑ Yes <br />❑ No (if no explain in remarks) I / I / f G, ❑ Faxed <br />Signal e of Service Agent Service Agent's License No. <br />Print Name of Service Agent — <br />MEASURING DEICES PLiACED IN SERVICE <br />WEIGHING <br />OR <br />O. ut oforder <br />Device <br />Number <br />Model N <br />Serial Number <br />Device Type (if device is new Capacity Tag Number <br />and marked) <br />Location <br />Manufacturer <br />4- <br />Cti�C(J1J-� <br />�ycttSGa <br />3r�is <br />-77Z le — <br />a <br />L1 � f <br />V Iii+ <br />et� 4 <br />2v,y1-/33 <br />'✓ <br />2� (� <br />I <br />tc <br />v D <br />C� � <br />�, � ;,kst. <br />aLI I I I�uL <br />w H <br />&Cj7_1c _ <br />—,/A <br />3`1 <br />Remarks: <br />applicable Date placed in service Date this notice was: El Mailed <br />Tags enclosed if app � / <br />❑ Yes <br />❑ No (if no explain in remarks) I / I / f G, ❑ Faxed <br />Signal e of Service Agent Service Agent's License No. <br />Print Name of Service Agent — <br />