PLACED IN SERVICE REPORT

PLACED IN SERVICE REPORT
Must be submitted to (placedinservice@ldaf.state.la.us) within 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. *

New Installation Replacement New Installation Addition Rejected Device Other Repair
Remarks:
Date: *

Month Day Year
Date
Device Owner: *
Device Location: *

Street Address

Street Address Line 2

City

Zip Code
State *
Parish: *
Phone Number: *

Area Code Phone Number
Email: *
example@example.com

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device

	Type of Device	Capacity	Make	Serial No.	Model No.	Location of Device