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Elite IV Contractors <br />2535 Wigwam Dr. <br />Stockton, CA. 95205 <br />Phone: (209) 461-6337 <br />Fax: (209) 461-6342 <br />P.O.# / Work Order#_ <br />PLACE IN SERVICE NOTICE 0 NOTICE OF SALE, LEASE, LOAN <br />Date Service Agency Registration No. <br />County f <br />- <br />LOCATION OF DEVICE <br />-,- �r n,) City Zip <br />Name of Customer Address / <br />Z r�--�—ftl� l� <br />Remarks: <br />rags enclosea a appu�a1 <br />❑ Yes ❑ No (if no explain in remarks) I (I Cl <br />Signa of Service Age <br />Print e of Service Agent <br />Date this notice was: ❑ Mailed <br />❑ Faxed <br />Service Agent's License No. <br />WEIGHING OR MEASURING DECICES PLtACED IN SERVI out E' <br />Model Number <br />Serial Number <br />of order <br />Device Type (if dert,evice is new Capacity Tag Number <br />marked) <br />Device <br />Location <br />Manufacturer <br />and <br />/v1Gc� <br />�y���.v-3iCP33 <br />AIC)Zv1F- <br />—' <br />�s-I- <br />UDS <br />L �`3s Z - <br />Sifea <br />AL�'LL� <br />I Y `e X kelj <br />{J <br />Uj7� <br />V+�v <br />CZS5z� <br />CL%;�- <br />V J I <br />Remarks: <br />rags enclosea a appu�a1 <br />❑ Yes ❑ No (if no explain in remarks) I (I Cl <br />Signa of Service Age <br />Print e of Service Agent <br />Date this notice was: ❑ Mailed <br />❑ Faxed <br />Service Agent's License No. <br />