Serviceperson's Placed In Service Report — Kermit the Frog Fire Protection

Issued in accordance with the Tennessee Serviceman Registration Act, T.C.A. 47-26-508. Only devices used in commercial transactions are to be reported.

Establishment

Name of Establishment where the device is located *

Street Address of Establishment where the device is located * No PO Boxes or Rural Routes

City *

Zip *

County *

Device

Device Manufacturer *

Serial Number *

Type of Device * Truck or Livestock Scale, Computing Scale, Retail Dispenser, LPG Meter, Wholesale Meter, etc.

Serviceperson

Name of ServicePerson *

Company Represented *

Registration number * Your Tennessee serviceperson registration number, per T.C.A. 47-26-502

Date *

Remarks

Signed * Typing your name here is your certification under the oath above.

3 of 5 free uses left.

This form is the only acceptable format for reporting weighing/measuring devices placed in service in Tennessee, and one copy must be submitted within twenty-four (24) hours of placing the device in service. AG-0731 · RDA 10172