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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
Addr
ess
Addr
ess
City
State Zip City State Zip
Signature Date Signature Date
26
State of California
Department of Health Services
Water Treatment Device
Certificate Number
Date Issued: May 30, 2000
Date Revised: February 9, 2001
143400 -
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
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