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~GITI~IVG ~7 ~"VI[. <br />NAME: CITY ~' ~UENE <br />JAB ADDR~a~ ~T99 TAIT~3 BTREET <br />_~..---~~w~ _-- .._..----._ ._ __-- <br />BILL T~; <br />. I~A~IE: A~I~E A ABOVE <br />BI~LIN ADD[~BBw '18~~ R~~aEV~LT BLVD <br />CITY ^ ~~fwMI~E TATE^ ~~ ~~I~w ~~~~~ <br />J~TT e ~CI~IBTI ~ I <br />~~IDfVE ~r -6~~~4~~~ <br />°1Q ~.t~ ~~~ gill be charged on a~c~u~t~ <br />afar D dais fat ~~ <br />ray r~l fir ~ <br />r~chl~#~~ver r ri <br />Thank You For Your Patronage <br />5?.00 <br />SUB TOTAL $57.00 <br />_..~:~,~ <br />TOTAL AMT $57A0 <br />~~ ~ ~~~~~~~.r'~j <br />~~ ~~ <br />~~ <br />B~A~~ DATE <br />D9l~ 8~~~ <br />C~I~~ DATE <br />~~#~ ~~~ <br />~P~ E~RCE <br />~~~~~ <br />~,~ ~ ~ ~ <br />{ ~~ <br />~ -~ ~~ ~. <br />--- - DATE BERVI~E DE~I~TI~N ~'~TAL <br />