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[:7-1 Billable <br /> SERVICE REPORT 11=1 Factory Warr. <br /> I[= Maintenance <br /> ' ,. PETROLEUM A&MA NrFntn eo of Billable <br /> FRESNO,CA <br /> (559) 1730 * Fax:(559) •1735 * 3887 N.Valentine Ave.'* Fresno,CA 93722 License No.779267 Id !o <br /> Please Visit Our Website: www.icservices.com N 0- 99648 <br /> Name: <br /> Service <br /> Address: , �- RC1 Date: <br /> City: 1 Zip: Phone: Work Order 0 <br /> Dispenser Make CustOrder 0 <br /> Dispenser Model: CloseCo,nr. <br /> Dispenser Serial : Parts Order 11 <br /> Pump Test: Gallons: Dollar Amt: <br /> Description of Work Performed <br /> p .Cl <br /> eAs <br /> DATE COMPLETE i I, give authorization to LC Services <br /> Prtn4 Wame <br /> na ®sasm rim s m®�:® a to run y credit card as form of payment. <br /> a mr�r+e aa�e ere �q � b carom <br /> �� "rte e�+� Q �°�• '� Card Type: Card#: Billing Zip: <br /> m ani <br /> gas <br /> moft.Wyw assign,tolry ,q Exp Date: / / Security Code: <br /> Sao ..WASUP"Win"mwadre. . <br /> Name on Card: <br /> ��,eo M1c atm Rao ena � <br /> orkAuthorized by Date <br /> • r Print Name <br /> Qty Part No. Inv. Description&SIN Each Amount <br /> Loc# <br /> " . - <br /> rkeT ' ate Depart Arrive Depart stop Orr <br /> ®y,,C Total Labor <br /> Total Parts <br /> Mileage <br /> Travel <br /> Sales Tax <br /> Total Amount <br />