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[]
[null,null,null,"Solicitação para Rompimento de Selos",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data: ",null,"/",null,"/",null,null,"SRS"]
[]
[]
[]
["Endereço",null,null,null,null,null,null,null,null,null,null," Nº",null,null,null,null,null,null," Complemento"]
[]
[]
[]
["Bairro",null,null,null,null,null,null,null,null," Município",null,null,null,null,null,null,null,null,null,null," CEP"]
[]
[]
[]
["Motivo"]
[null,"Alteração de carga",null,null,null,null,null,"Relocação",null,null,null,null,null,"Manutenção",null,null,null,null,"Outro(especificar):"]
[]
[]
["Local do selo existente"]
[]
[null,"Tampa dos bornes do medidor",null,null,null,null,null,null,null,"Porta do compartimento do disj. geral",null,null,null,null,null,null,null,null,null,"Tampa da caixa da TR"]
[]
[null,"Tampa do painel seccionador",null,null,null,null,null,null,null,"Tampa da caixa de distribuição",null,null,null,null,null,null,null,null,null,"Outro(especificar):"]
[]
[]
["Nº dos selos retirados"]
[]
[]
[]
["Numero(s) do(s) medidor(es) envolvido(s)"]
[]
[null,"Todo o PC",null,null,null,null,null,null,null,null,null,null,null,"Nº   ________________",null,null,null,null,"Unidade"]
[null,"Nº de medidores:",null,null,null,null,null,null,null,null,null,null,null,"Nº   ________________",null,null,null,null,"Unidade"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Nº   ________________",null,null,null,null,"Unidade"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Nº   ________________",null,null,null,null,"Unidade"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Nº   ________________",null,null,null,null,"Unidade"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Nº   ________________",null,null,null,null,"Unidade"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Obs: Incluir relação em anexo, caso o número de itens seja insuficiente"]
[]
[]
["Responsável técnico"]
[]
["Nome"]
[]
[]
["Número do registro profissional",null,null,null,null,null,null,null,null,null,null,null,null," Assinatura"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"__________________________________________________________"]
[]
[]
["Cliente"]
[]
["Nome"]
[]
[]
["CPF/CNPJ",null,null,null,null,null,null,null,null,null,null,null,null," Assinatura"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"__________________________________________________________"]
[]
[]
["Data da solicitação",null,null,null,null,null,null,null,null,null,null,null,null," Data prevista para a regularização"]
[]
[]
[]
["Autorização"]
[]
["Agência",null,null,null,null,null,null,null,null,null,null,null,null,null,null," Telefone"]
[]
[]
[]
["Atendente",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," Matrícula"]
[]
[]
[]
["Nº Contato",null,null,null,null,null,null,null,null,null,null,null,null," Assinatura"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"__________________________________________________________"]
[]
[]
[]
["A autorização se restringe exclusivamente ao selo plástico dos locais relacionados. Não é permitida violação de outros dispositivos de segurança sem a prévia autorização da Light."]
[]
[]
[]
["Ao concluir os serviços a Light deve ser informada imediatamente para providenciar a regularização da instalação"]

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