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Modesto Bottled Water Inc <br /> PO Box 4&q 3 <br /> Wdesto CA <br /> R 5f1 Modesto CA 95357 Pccount rR � <br /> (209)527-6764 <br /> Charge Code <br /> f a 16846 <br /> Service Address Date _ - D C, r t�� b-T, <br /> � E }�/1� 7,t 1 e Phone No 01 - <br /> 1-72 <br /> 1 yLu✓ Route No }� - I <br /> Zip 9 K3 3`7 Equipment &314 T e <br /> BillingAddress fir^'n}-a r ±fie .-, of Serial No 7 <br /> 3C5 -ri W`I�+^ Q d� _ Rental 5 9, 23 Psr m c\ 4 <br /> .Mfwif'e[c -71p S Reference <br /> Home Office Phone Ref Phone II <br /> owner/Employer Phone I <br /> Home/Empbyer Address Zip <br /> S S# BusineWDmvers be No <br /> �iz�1,✓ H f Y 111 -YY, <br /> NONfAXAiLEE ' CQD . Q1Y f %%UN€FPRE`, :,AMQUNI� <br /> Wy k x h, > ,4i H.% 4ifiYiSi,�rf'�'D/•Yy% �r'r��l. i ii s s '^a" '! <br /> t r 2 Co 13 <br /> TAXABLE SA FC { <br /> Cups 42R 450 S[yro t <br /> BOTTLE DEP09TS <br /> bocce HacUes <br /> on Rand Reamed Sales Tax w ._ <br /> TOTAL GU <br /> SOUP NO (SE-1 IPUI <br /> on Acwvu <br /> Equipment tease <br /> lam the Cus r a rr d by rhe Customer Agreement Prcepted initial <br /> to accept f�e terms f is agreement and Accepted d sto Bottled Water, Inc <br /> have reCei rhe i Mems <br /> By By <br /> Title Date Installed + <br /> Pmt N.-me <br /> n.ur OFFicr Wltlrr Cu$TOWFIZ YrULOW KCOUM HNK <br /> nn FVINTMC IXM 11 1111 <br />