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Elite IV Contractors <br />2535 Wigwam Dr. <br />Stockton, CA. 95205 <br />IT PLACE IN SERVICE NOTICE <br />County <br />i 0019 Phone: (209) 461-6337 <br />Fax: (209) 461-6342 <br />P.O.# / Work Order# <br />NOTICE OF SALE, LEASE, LOAr <br />Date Service Agency Registration <br />No. <br />LOCATION OF DEVICE <br />lame of Customer Address �'H/r 9,2r r 'l�I �Pty Zip <br />. —T"1 Tdl "1L1crTf1UQ nr A VV" TV cFRVTf F. <br />W Jr 11T111['1 <br />Cert. of Conf. No. <br />-- <br />Out of Order <br />Device <br />Manufacturer <br />Model Number <br />Serial Number <br />Device Type <br />(if device is new <br />and marked) <br />Capacity <br />Tag Number <br />Location <br />n <br />I <br />252 z-1 <br />� l <br />._ <br />U <br />A&toc)5L u(! <br />U�1 <br />VD U, <br />?s�?zs <br />- <br />v'Si <br />v Sa <br />Z3��x <br />czt���43� <br />WAN <br />— <br />� z– <br />Remarks: <br />if a licable <br />Date placed in7service Date this notice was: ❑ Mailed <br />Lenclosed <br />Yes No (if no explain in remarks) <br />�� ❑ Faxed <br />Print Name of ervice Agent <br />Signatur Service Agent Service Agent's License No. <br />