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Modesto Bottled Water Inc <br /> / PC)fbx9G93 <br /> Mnd(slo CA 95352 /�Ccotfill <br /> W11521069 <br /> Charge Code <br /> 17687 <br /> Service Address Date <br /> r r 1c Phone No <br /> Route No <br /> 4 Zip ?� ? Equipment Type <br /> Billing Address Serol No w f� <br /> + v + ✓ if Rental 5 ] Per _c, <br /> ' � S3 <br /> Zip Reference <br /> Home Office Phone <br /> T� p Rer Phone <br /> Dwner/Empbyer y_vt.�_ Phone <br /> Horne/Employer Address Zr <br /> 5 S# Susrness/Dnvers be No <br /> W� [ <br /> u C D� <br /> ; y NUN )it SA <br /> E T.>`5",ry��. " <br /> TAXq �k QT!.�,4y.�YNrr PRICE AtJ}OUM��, <br /> t e ! Z <br /> TAXABLE SALES <br /> Cups 12R <br /> BQrr1E DEFt7SITS ' /o <br /> on H�d Sales Tau <br /> EQUIP NO ISET} trv) <br /> Rcce,eetl -'� ChRk , (� T Cam 1 I - — <br /> on&fo,xu J }Y�C7r1� <br /> ACC <br /> !qu aprrx nt Lease <br /> I am the C s[orrKr w ihofj,ed by 11 Cusrorrx r Agrccrnenl Arcepted rnUal— <br /> to dreep [tic [( )f this agrcemenr mi(i <br /> hdvc reser ed the v listed items &LCpt,�d Modesto Bottled Water Inc <br /> Illy - -- r -- - By � <br /> nrrK> w,un cu�um,,Ivniie,w ncC[x�nrur„c� i <br />