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Canon <br />CANON USA, INC <br />Today's Date: March 21, 2017 <br />REMOVAL INFORMATION: <br />Requested Removal Date: April 5, 2017 <br />Serial Number: JMQ03263 Model Name: IR5250 <br />For CFS Use- Servicing Dealers Name: Yakima <br />For CFS Use- Canon State Contract# : WA State Contract NASPO 05214/3091 <br />CURRENT LOCATION INFORMATION: <br />Company Name: Kittitas CO WA - Public Health <br />Street Address: 507 N Nanum # 102 <br />City: Ellensburg, <br />Location Removal Contact: Candi Blackford <br />Phone: 509-962-7515 E-mail; us <br />Alternate Removal Contact: Candi Blackford <br />Phone: <br />E-mail: csndl.afackfor($Aw.i illitag.wa,gg <br />County: Kittitas <br />State: WA ZIP Code: 98926 <br />Mobile #: <br />iT ne loyal <br />ADDITIONAL INFORMATION: <br />Is a Certificate of Insurance needed? Yes: No: x <br />If yes, please provide COI Requirements when completed form is submitted. <br />Is security clearance needed? Yes: No: x <br />Is Hard Drive removal & replacement needed? <br />If yes, please provide the PO# below & a copy of the purchase order when this Yes: No: x <br />completed form is submitted. <br />Hard Drive removal & Replacement PO# : <br />Please provide any building requirements (ie: no elevator access; stairs will be involved; loading dock or <br />truck restrictions, etc): PLEASE DO NOT remove old machine until new one is in place. Located in <br />Copy Room 4.26.17 <br />Is this machine being replaced with a new machine? If so, please provide an ETA of the new machine <br />I <br />To ensure your removal request is processed in a timely manner, all information above must be <br />completed in full. Please email completed form to: assetrecovery@cusa.canon.com <br />Thank you for your business! <br />Canon U.S.A, Inc, w Asset Recovery Team w One Canon Park w Melville, NY 11747 <br />