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ace" Sell <br /> a' aic C (coran rnmard �1 � �Ai' : ? Q «?j ��1C ►�"i� (� <br /> r. <br /> Registered Service Agenc Location of Device <br /> ` Name *Company / <br /> U ht . ►J �� Name I i� i !�L CIJ <br /> "AddressAddress <br /> 20 <br /> C,rd -r r� <br /> *Gity, ` city <br /> State <br /> , Zip state , Zip `, 12 <br /> Phone ( Oil 7Z3 - A�03, , L4 bZ . ;'County <br /> i / 7_ �!• � ��v l��xv i .` <br /> * Date of <br /> V�9aw-ne Repair or <br /> Placin <br /> g � l 'Z U <br /> License 9 7into <br /> Service <br /> IDevice 11aivormation <br /> * Device <br /> I Er cc <br /> I ® * Device Vflodf I *Serial Number Type of Dei;lce <br /> (i. e., Pump Manufacturer Number NIULr�ah, err' device or t;a act � if .ao !,cable <br /> or check i' ( p applicable) <br /> ) <br /> stand # component) <br /> 3 - <br /> Remarkse -- - - — <br /> �_ r� <br /> H S: S Energy, LLC 0 t. ! l�"� 1�j i� Z Z t✓ � � � 7L) y L � �- G V X11 <br /> 714 76 1 -5426 <br /> Registration # 3776 � ti5 11 Hr 1 Det t�lU �t �' <br /> Jesus , ( Jesse) Romero License # 31360 , 'r C �y t e VL ► � ( 1�-"� ,�l tS "2� <br /> DATE : x- 31 " D! <br /> " <br /> REQUIRED 1NFORMRTION Reference: Califon fa . Code of Regulations, Title 41 Division 9, Chapter 4, Section 4085 (a)(2) <br /> 1 :, ,-old -]- + z- � 8 �� f2 <br /> Link to county contact inforranation: <br /> http ://www.cdfa . ca . gov/exec/coLiiib /documents/countycommissionersealercontactinfa pdf <br />