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do <br /> J lJ N p 7 2017 <br /> Elite IV Contractors Phone: (209) 461-6337 <br /> 2535 Wigwam Dr. EN\1iR0NjV,FNTALHEALTH Fax: (209) 461-6342 <br /> Stockton, CA. 95205 p-r%AF4 J P.O.#/Work Order# <br /> IF PLACE IN SERVICE NOTICE Q NOTICE OF SALE,LEASE,LOAN <br /> County Date Service Agency Registration No. <br /> �a <br /> 17 <br /> A6l0 �flb Zv/� r <br /> LOCATION OF DEVICE <br /> Name of Customer Address City Zip <br /> 1 D H STOGY 9521 <br /> WEIGHING OR MEASURING DEVICES PLACED IN SERVICE <br /> Cert.of Conf.No. Out of Order Device <br /> Manufacturer Model Number Serial Number Device Type (if device is new Capacity Tag Number Location <br /> and marked) <br /> 5'V 4A P1 p <br /> i 9r1Gp $DQ �lol? 0� <br /> Remarks: <br /> 1 h►STA[L-Z 0 JV E v-J V67 /4622 .9 <br /> Tags enclosed if applicable Date placed in service <br /> Date this notice was: 13 Mailed <br /> ❑ Yes No(if no explain in remarks) f l / ❑ Faxed <br /> Print arae of Service Agent Signatur of S rvice Agent Service Agent's License No. <br /> .�9 L � 2 <br />