ACS-14-13 PLACED IN SERVICE REPORT ADA

PLACED IN SERVICE REPORT
Must be completed (with 10 days) after installing a new or used commercial device, restoring a condemned or rejected commercial device to service, or performing major repairs to a commercial device.
Type of report:
Remarks:
Date:

MonthDayYear
Device Owner:
Device Location:

Street Address

Street Address Line 2

CityState

Zip Code
State:
"Only Louisiana Allowed"
State:
Parish:
Phone Number:
"Enter Numbers Only"Format: (000) 000-0000.
Email:
example@example.com