SHIP TO
Name _________________________________________________________
Address ______________________________________________________
City _________________ State/Country ___________ Zip ________
Phone # (Day) _________________ (Evening) ___________________
Customer # ________________________ PO# ______________________
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Qty | Prod # | Description |Price | Total
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Other Size & Quantities available upon request.
All Prices subject to change without notice.
Method of Payment
( ) Check/MO ( )M/C
( ) Visa ( )AMEX ( ) Discover Shipping* _______
Card No.____________________ 8.25% CA Sales Tax_______
Exp. Date __________________ COD (CASH) $5.00/Box_______
Signature __________________ Add $10.00 UPS Hazardous _______
Ship'g (EZ-LAM Gallons Only)
TOTAL _______
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