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Dec 27 2816 16:58:86 CST FROM: F'M/58846389811 MSG# 1736935481-885-1 PAGE 812 OF 862 <br /> Pickup Recolpt <br /> 15305 Spring live <br /> Sanla Fa SpHpix, CA 90670 Pickup Pat*: 41MOIrs, <br /> MpUlerrind End Us®raratity EDT Man)festu: 1101366414 <br /> Truck: 423468 COT Trip Log 9: 513304 <br /> t,lggnsa ?4Umber: Stub;AZ I ITR960 <br /> State: CA <br /> Docai: 13.06936 Store No.:WA01564 <br /> WAL MART STOCKTON <br /> 322.3E HAMMER LANE <br /> STOCKTON,CA 95*212 <br /> Telephcrni y:209,x473.3438 <br /> TPID: 1.331982-01 <br /> ITEM <br /> (QTY <br /> Tlartat �2rst .__ _ ... ,_ ... . <br /> W holo Ti w <br /> I oorYliy that trttd+lr pOWY cif P irJury undar the town of tlp Stnta o! 1 oortfty OT1A under penal Iy of pvrlury undartlw town of rtm siote of <br /> aloe nttl,IMt the Inlarn&,k1ft prOviclad curve 16 true And Cormoj, t;pllh)r Wlhat thn Intormnllon pprovtd.+d JIpove Ip It-and cprmct, in <br /> addition.I am awaro rtrat Wsw-avon or lhle Intbrmauon"ymgult If, <br /> ouspenalon,revocallon,or donor of renBWal of the Wa3t9 Tlrn Haular <br /> 0"holrallon pursuant ro.hurtlo Rasuurc s Cate.soCttarr A2980 and may <br /> rowl in clvn ponamon up to 525.0tm per day,per vktlatlon ov <br /> aWftnkS•trmxllva I)enafliep up!Q 55400 par vlotetjcn per dayao deacrfAed <br /> In Pupdc kaewroee Cede soolon 42962. <br /> Gpnemlor Signature Driver Siflnalure <br /> No Slgn©r JORGE 10ELO <br /> /ffd <br /> x <br /> 1 yAf L <br /> i <br /> l <br /> Corifldentlality Claim,.Tho Inlormaticm pmvldod On IN11i form rihould bo conaldtred oor4danual,proviwary,andlor trade <br /> V ?A eaGTnt.In ncparden,a0 with T hW 14,CM$acilon'17'049 ai,paa,atrould any mombw'Of Ny PUNIC roquomt(fivel nlurn of thla <br /> lnfarrnotlOn,I Iv.R0e61 that Cntfilec;"content nA.dt tee od(Imea and totahtw.ira nuatrbor atrdve, <br /> I. <br /> 'r't rC Gleefronle Rapartlnp Re C.ltlArycb:l.hWn Tire Wnitt Harr thenourhaorati by CatRrtGyWn to poorticipefn In me tMnsta and t <br /> Used Tim MANfast EQT ulllalmnic rvi"Nmo pr6orarn_on b"I of llta cuotamRT llotod on thio tprm.Laklrf The Wow WM f <br /> eirelrankaRy lraniml!tri Co!Reaytkt all rMgClmd 1rlbmntiO4 from INS mon Neat. CalRecrcle hen annr*.r,a ltd'Iakln nrw <br /> W~IrDT fdMl;ror uep.,m111111 tha Waa;V The Nunitest$ypiorn f'?t)t'txoi?rAm. <br /> F <br /> rS <br /> r <br /> k <br /> c <br /> r <br /> t <br />