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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
Stat e of Califo rn ia
Department of Health Services
Water Treatment Device
Certificate Number
Date Issued: February 2, 2005
Trademark/Model Designation
Replacement Elements
169805 -
MWF MWF
Manufacturer: General Electric Com pany
The water treatment device(s) listed on this certi cate have met the testing requirements pursuant to Section
116830 of the Health and Safety Code for the following health related contaminants:
Cysts
Turbidity
Asbestos
Lead
Mercury
Ala ch lo r
At ra zin e
Be n z e n e
Carbofuran
Li n d a n e
Mercury
To xa p h e n e
1,4-dichlorobenzene
2,4-D
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 certi ed fo
r
cyst reduction may be used on disinfected waters that may contain lterable cysts.
300 galRated Service Capacity:
0.5 gpm
Rated Service Flow:
Conditions of Certification:
35