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(916)355-0300 DELIVERY TICKET <br /> NSA D'1 MIX,INC. <br /> 6 WEIGHMASTER CERTIFICATE AGENT COPY <br /> r-1,11374 Gold Dredge Way•Rancho Cordova,CA 95742 THIS IS TO CERTIFY that the following described commodity was weighed,measured,or counted <br /> ❑9700 Del Road•Roseville,CA 95747 by a weighmaster,whose signature is on this certificate,who is a recognized authority of accuracy, <br /> OFFICE: 3401 Fitzgerald Road•Rancho Cordova,CA 95742 as prescribed by Chapter 7(commencing with Section 12700)of Division 5 of the California <br /> PLEASE SEND ALL PAYMENTS TO THE OFFICE ADDRESS. Business and Professions Code,administered by the Division of Measurement Standards of the <br /> California Department of Food and Agriculture. <br /> OWNER/AGENT/CONSIGNEE <br /> ON •DATE LOADTIME LOAD <br /> I <br /> BATCH SLUMP TICKET NUMBER TRUCK#/DRIVER WEIGHMASTER: <br /> FOLSOM <br /> DEPUTY <br /> This agreement requires compliance with the requirements Yes❑ NO H20 ADD GALLONS TIME EST.YDS. <br /> of the Public Labor Code and falls under AB219. le <br /> Regarding the Property Damage Release,Excessive Water Usage,Health Warnings and AB219,my signature 2"d <br /> acknowledges that I agree to all Terms and Conditions of this delivery as stated on the reverese side. 3'd <br /> PRINT NAME: SIGNATURE: Additional: <br /> X — X <br /> DEPARTED PLANT ARRIVED JOB START UNLOADING COMMENTS UNLOAD TIME <br /> RETURNED TO PLANT LEFT JOB FINISH UNLOADING TIME ALLOWED <br /> ADDITIONAL CHARGE 1 <br /> TOTAL ROUND TRIP TOTAL AT JOB UNLOADING TIME STANDBY TIME ADDITIONAL CHARGE 2 <br /> CODE DESCRIPTION <br /> BATCH FORMULA <br /> 127".16 <br /> FR-06(REV.07/16) <br />