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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