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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: June 10, 1997
Trademark/Model Designation
Replacement Elements
129197 -
GE Water by Culligan Filtration System FXRC None
Manufacturer: Culligan International Company
The water treatment device(s) listed on this certificate have met the testing requirements pursuant to Section
116830 of the Health and Safety Code for the following health related contaminants:
Cysts (protozoan)
Turibidity
Lead
None
Microbiological Contaminants and Turbidity
Inorganic/Radiological Contaminants
Organic Contaminants
Do not use where water is microbiologically unsafe or with water of unknown quality, except that systems
claiming cyst reduction may be used on water containing cysts.
200 gallonsRated Service Capacity: 0.5 gpm
Rated Service Flow: