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I <br />NORTHWEST PUMP+ & EQUIPMENT . <br />2545 North Ontario • Burbank, CA 91504 - tel 818.409.3030 - fax 818.409.3050 <br />NWP REGISTRATION FORM <br />OPW EVR Phase I Re -Certification Training Course <br />WHEN: Thursday June 30, 2011 <br />WHERE: Northwest Pump & Equipment <br />4433 Enterprise Street <br />Fremont, CA 94538 Ph ( 510 ) 656-7867 Fax ( 510) 657-3006 <br />TIME: 7:30 AM Check In Class Time 8:00 AM —12:00 Noon <br />PRE- REQUISITE: Previous OPW EVR Phase I certification is not required but field work experience is. <br />Cost: S25.00 per student <br />Company: fj I I we a Dow s r rv&T�oK> ►SCG Title: fu?,L 54 s-rewt -r4—,A <br />Student Name: N t(Aowtyc• t ot c ?-- Phone: 1([te - q t j - t -i l l ( <br />Address: 41410 Ya w tcc a 14'.0 2.j it zoo,[,11 tA,. Q S'� �- <br />FAX: a l Le- &Z S'=yg 1 { Email P V a t ofy� to - . i 1 uj e - - C.o w% <br />3 AMEX 3fISA ❑ MasterCard <br />Card # y k $ S I b o q4&(. 3 #{ tog CCV# 64 lb Exp Dateoff t I <br />'Email copy of credit card receipt to: Xf'y Q - ( y end' CD tit. <br />Return this registration form to scastan ,nwpumn.com or Fax ( 818 ) 409 — 3050 for QBCh student. <br />Course fees must be paid with registration form Any cancellation must be done 72 hours in advance. If we <br />do not achieve minimum enrollment, the class will be cancelled. <br />Class size is Iimited to no more than 25 students. <br />Portland, OR • Kent, WA • San Diego, CA • Fresno, CA • W. Sacramento, CA • Fremont, CA • Burbank, CA <br />Spokane, WA Phoenix, AZ • Anaheim, CA • Anchorage, AK • Honolulu, HI Las Vegas, NV • Pasco, WA <br />wwwnwni im n rnm <br />