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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
State of California
Department of Health Services
Water Treatment Device
Certificate Number
Date Issued: May 30, 2000
Date Revised: February 9, 2001
1434
00 -
GE Smart Water Filtration Systems - GWF06
GWF06
GE Smart Water Filtration Systems - GWF
GWF
Hotpoint Refrigerator Systems - HWF
HWF
General Electric Appliances
Cysts (protozoan)
Turbidity
Asbestos
Lead
Atrazine
Lindane
2,4-D
300 gallons*
0.5 gpm