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f Modesto Bottled Water Inc <br /> Mcrdc s10 CA 95357 &COUnr <br /> (209)527 6764 <br /> Charge Code <br /> y <br /> 117685 <br /> Semce Address _ Date " IX,Up <br /> Phone No <br /> I 7n Route No — <br /> �, Zip� ._Z Equipment�TR �,I f Pc�i of �c*,C�/(� <br /> Billing Address(,;;� ,�C +�1 r,�._ Serial No J��12) ? ] !S <br /> z�S I ,,, Rental S <br /> Per/11If>� <br /> O� <br /> 7 I r 4 Zip r ) 3 Reference <br /> Home Office Mlone ( Ref Prone j <br /> Owner/Employer Phone <br /> Home/Employer Address Z o I <br /> S S# G <br /> Business/p r s LK No <br /> i <br /> 60DE <br /> „�aoHraxns�µsar s _ � on kt NTPRICE ff yY All,"11 s <br /> ,4u Ijoi a <br /> L e # +;C <br /> , I <br /> TAXABLE SALES i <br /> Cups 42R 450 Styro <br /> BOTTLE DEPOSH5 <br /> U {J� <br /> Bottles Bowes <br /> on Hwd ReR,med Sales Tax <br /> TOTAL S-t) <br /> EOUrP the 1%7) <br /> Reee,�ed �� y Check <br /> n Casrt I i <br /> on Mccx,nr 1 V !'h <br /> I <br /> ACCEFMCI:.f / Equrprrx nt tease <br /> I <br /> 1 am the Cus{ r rN a A),x)[fa d by4'�we <br /> r tOrl-M Aga ornc r It 11ccepted uutral_ <br /> t0 a['ePr e Fefms of tbdagnt andf <br /> r <br /> --- Acce_{x <br /> �cd, Modesto Bottled Miter IncIwvc r d ttx abuv�,h�ed ae <br /> By 13 <br /> I <br /> �_- <br /> 1 ' <br /> Prtk - _ _ f)atr lntr3lkd <br /> 'diki W,Hr( C1151C Nv,rr t,I,(,W /r CCx lrlrrN( rir� ' <br /> �1r rxrn 31 J 17 ; <br />