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NOTE <br /> ® l„ri.r i , PMOVNT <br /> LQA <br /> a 1� CE <br /> OVAN l�Y. Ca UAN nr I'll <br /> eau,"', <br /> —_ <br /> Wafer Added Curb Line Crossed At Owner's SUB TOTAL <br /> 1 IN GALLONS: Agent's Request: O <br /> AUTH00.1ZED SIGNATURE TAX <br /> Print Name: Data TOTAL <br /> X Signature above signifies receipt and acceptance of the 1',med mate .1a and acknowledge- <br /> INITIALS INITIALS ment of antl ayreement to Ile CEMEX leans and condners. <br /> BATCH DATA: _ <br /> i <br /> a <br />