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Elite IV Contractors <br />2535 Wigwam Dr. <br />Stockton, CA. 95205 <br />Zf <br />PLACE IASERVICE NOTICE <br />�; <br />Phone: (209) 461-6337 <br />Fax: (209) 61- 342 <br />P.O.# / Work Order# , <br />0 NOTICE OF SALE, LEASE, LOAN <br />County Date Service Agency Registration No. <br />11 !f G < <''� 2278 <br />LOCATION OF DEVICE <br />Name of Customer <br />Address <br />City <br />Zip <br />�, /&//e <br />d fi <br />Out of Order <br />Tag Number <br />C f� <�`� . <br />1ST ✓ t <br />�Cf <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 />/ <br />a �� <br />Lz1v <br />REC.4;'EIVED <br />DC <br />18 203 <br />ENVIRONMENTAL <br />EALTH <br />DEPARTMEt <br />T <br />Remarks: ' <br />3 <br />Tags enclosed if applicable <br />Yes I NO (if no explain in remarks) <br />Date placed in service <br />'/� � 1,5 � /.,�/ <br />Date this notice was: Mailed <br />` -1 [Faxed <br />Print Name of Service A entf <br />Signatu •e of Slice A�ge�t a <br />Service Agent's License No. <br />