For Purchases Made In Iowa:
This form must be signed and dated by the buyer and seller prior to the consummation
of this sale. This form should be retained on file by the seller for a minimum of two years.
BUYER:
SELLER:
Name
Name
Address
Address
City
State
Zip
City
State
Zip
Signature
Date
Signature
Date
26
State of California
D
e
p
art
m
ent of
H
ealt
h
Ser
v
i
c
e
s
Water Treatment Device
C
erti
f
icate
Nu
m
b
er
Date Issued:
F
e
b
r
u
ar
y 2, 2005
Tra
d
emar
k/Mod
e
l
De
s
i
g
nati
o
n
R
e
p
l
acement
E
l
ement
s
1698
05
-
MW
F
MW
F
M
an
uf
act
u
rer
:
G
eneral
E
le
c
tri
c
Co
mp
an
y
The water treatment device(s) listed on this certificate have met the testing requirements pursuant to Section
1168
3
0
o
f
t
h
e
H
ea
l
t
h
an
d
S
a
f
et
y
C
od
e
f
o
r t
h
e
f
ollo
w
in
g
h
ea
l
t
h
re
l
ate
d
c
o
ntaminant
s
:
C
y
s
t
s
T
u
r
b
i
d
it
y
A
s
b
e
s
to
s
L
ea
d
M
er
c
u
r
y
A
la
ch
lor
A
tra
z
ine
B
en
z
ene
Car
b
of
u
ran
L
in
d
ane
M
er
c
u
r
y
T
o
x
a
ph
ene
1
,
4-
d
i
ch
loro
b
en
z
ene
2,
4-
D
M
icr
o
b
i
olog
ica
l
C
o
ntaminant
s
an
d
T
u
r
b
i
d
it
y
I
n
o
r
g
anic
/
R
a
d
i
olog
ica
l
C
o
ntaminant
s
O
r
g
anic
C
o
ntaminant
s
D
o not
u
s
e
w
h
ere
w
ater i
s m
i
c
ro
b
iolo
g
i
c
all
y u
n
s
afe or
w
it
h
w
ater of
u
n
k
no
w
n
q
u
alit
y,
e
x
c
e
p
t t
h
at
s
y
s
te
ms c
ertifie
d
for
c
y
s
t re
d
u
c
tion
m
a
y b
e
u
s
e
d
on
d
i
s
infe
c
te
d
w
ater
s
t
h
at
m
a
y
c
ontain filtera
b
le
c
y
s
t
s
.
3
00
g
al
R
ate
d
S
ervice
C
a
p
acit
y
:
0
.
5
g
pm
R
ate
d
S
ervice
F
lo
w
:
C
o
n
d
iti
o
n
s o
f C
erti
f
icati
o
n
:
