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DATE <br /> PSI FACT TY NUMBER - <br /> ',USTOMER REFUND (9 _ <br /> 51-t1SD EJR. <br /> NAME <br /> PHONE NUMBER <br /> ST <br /> :UEO'"�- T - <br /> d CRY STATETE 23P COQ <br /> STREET ADDRESS(ND P.O.BOXES) • ; pt . <br /> pv t cIC i( <br /> CUSTOMEfl SIGNATURE DRIVER'S LI ENSEA.O.NUMBER <br /> SECTION 1: GASOLINE Af _- <br /> F-1PUMPREAUTHORIZATION $ <br /> 010 " (Not to exceed$20) <br /> PUMP NUMBER- .— <br /> TIME <br /> REASON FOR REIMBUNSEMENT(E.G.STOLEN GASOLINE,BILL JAM.ETC_) rr <br /> SECTION 2: PRODUCT RETURNS <br /> ❑ CASH REFUND $ --_-- 1e9• Product returns,etc.) <br /> UNIT SALES TOTAL REFUND <br /> PRODUCT DESCRIPTION I REASON FOR RETURN QUANTITY PRICE TAX <br /> CASHIER'S SI <br /> STDME <br /> BUTX>N: WrerE. W YELL i <br /> i <br />