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(isi� FORWA SITE TICKET GRID INCORPORATED <br /> 399 South Austin Road/WEIGHING LOCATIONk" P O Box 6336 WEIGHMASTEFi <br /> Ma <br /> , CA 95336 Stockton, CA 95206 <br /> (209) 982-4298 /WEIGHING LOCATION Main Office (209) 466-4482 DATE IN TIME INa Recovery (209) 982.4936 Fax (209) 465 0631 <br /> DATE OUT TIME OUT <br /> VEHICLE ROLL OFF <br /> v , 4 <br /> REFERENCE ORIGIN <br /> r <br /> r <br /> ti <br /> QTY UNIT DESCRIPTION RATE EXTENSION TAX TOTAL <br /> X70- <br /> � o� <br /> VEIGHMASTER CERTIFICATE THIS IS TO CERTIFY That the following described commodity was weighed measured or counted by a weighmoster whose signature Is <br />,n this certificate who is a recognized authority of accuracy as prescribed by Chapter 7(commencing With Section 12700)of Division 5 of the California Business <br /> ind Professions Code administered by the Division of Measurement Standards of the California Department of Food and Agriculture _ <br /> NET AMOUNT <br /> • TENDERED <br /> CHANCE <br /> CHECK NO <br /> _ r <br /> f <br /> DRIVER'S SIGNATURE <br />• <br />