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CANON USA INC <br />Today's Date: March 21, 2017 <br />REMOVAL INFORMATION: <br />Requested Removal Date: April 5, 2077 <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 />County: Kittitas Street Address: 507 N Nanum # 102 <br />City: Ellensburg, State: WA ZIP Code: 98926 <br />Location Removal Contact: Candi Blackford <br />Phone: 509-962-7515 E-mail: .canr.ttt!lachlOrsl@cO,l<;l!!ilMW;!US Mobile#: <br />Alternate Removal Contact: Candi Blackford <br />Phone: E-mail: cal~CJI .()13cIllOI.Cl@co.l(j!llll1S \I/{I \J ~ Mobile#: <br />ADDITIONAL INFORMATION: <br />Is a Certificate of Insurance needed? <br />If yes, please provide COl Requirements when completed form is submitted, <br />Is security clearance needed? <br />Is Hard Drive removal & replacement needed? <br />If yes, please provide the PO# below & a copy of the purchase order when this <br />completed form Is submitted. <br />Hard Drive removal & Replacement PO# : <br />Yes: No:x <br />Yes: No:x <br />Yes: No:x <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 />To ensure your removal request is processed in a timely manner, all information above must be <br />completed in full. Please email completedformto:aes&trecoyerv@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