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 ReplacementNew Installation AdditionRejected DeviceOther Repair
Remarks:
Date:*

MonthDayYear
Date
Device Owner:*
Device Location:*

Street Address

Street Address Line 2

CityState

Zip Code
State*
Parish:*
Phone Number:*

Area CodePhone Number
Email:*
example@example.com