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t- <br /> 5 M000000o ; <br /> 0 <br /> E <br /> D <br /> I <br /> T <br /> 0 <br /> RJCLUDES APPLICABLE FEDERAL,SL47E AND LOCAL TAXES ON MOTOR VEHICLE FUEL,PAYMEN(OF WHICH MAY BE ASSUMED BY 76. <br /> s 2 61 1 19 4 DATE ---1 <br /> E 00363611 12.� ►�03 <br /> E M 215012 <br /> R <br /> D QTY. PRICE AMOUNT This transaction is subject to the terms and <br /> UF UNLEADED LEADED DIESEL conditions(as may be modified from time to time <br /> E <br /> GRADE with required notice)of the 76 Gasoline Credit <br /> Card Agreement as contained on the monthly j <br /> o SUPER PREMIUM HI-PERF. statement. <br /> GRADE SIGNATURE OF BUYER <br /> I 5 SERVKE <br /> ORDER NO. AUTHCj <br /> SALES TAX NO. RIZATION SVC.BY i <br /> ACCOUNTING COPY TOTAL 1 <br /> FORM 3-2K95(REV.11-9 PRINTED M U.S.A. ^'t- <br />