*1601 Las Plumas Ave*  
*San Jose, CA 95133-1613*  
*Ph: 408-347-3400*  
*www.therma.com*

## JOB SITE INFORMATION  
**JOB NUMBER:**  
**DATE:**  
**JOB SITE NAME:**  
**CONTRACTOR:** THERMA LLC  
**TECHNICIANS NAME:**  
**ADDRESS:**

## UNIT MAKE/CYL  
**UNIT MODEL/SIZE**  
**SERIAL**  
**REF WT**  
**TRANSFERRED TO**

1  
2  
3  
4  
5  
6  
7  
8  
9  
10  
11  
12  
13  
14  
15  
16  
17  
18  
19  
20

I hereby accept performance and charges as being satisfactory and acknowledge that the equipment has been left in good condition. Environmentally harmful refrigerants have been removed in compliance with section 608 of the Clean Air Act. Work has been completed by a Therma LLC location or an independently owned and operated franchise business.  
**Customer's Signature:**  
**Technician's Signature:**  
**THERMA LLC**