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` SIGN9TUREOR REGEF T .CONGRE7EANDACKNOWLDDGEMENTOF!, A,5 RWWARNING% `
asc meyer bnbJe ampany w no assume a I!tr any property ampge or any
equtp!»eht damage for any deif�YeXfeB beyond the cur4 lute
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SUB -TOTAL
..,AUTHbRIZED BY `T�
SNI ENT $U)-B.JECT TO CONDITIONS ON REVERSE SIDE®
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1142 Water Tower Road, Lake Park. FL. 33403
Office:1-877-484-9994 / Fax:561-844-7102
South. East Florida Division Dispatch: 561 =844-9994 / Central Florida 'Division Dispatch: 407-339-5311
Concrete Tested ❑ Yes 'k No LOT #
Water :deed at Customer's
Cylinders Taken p Yes [I -No
Request
Comments
gals. to full load
gals. to 2/3 load
gals. to 1/3 load
Customer's. Rep - Water Added
NOT RESPONSIBLE FOR
VARIATION IN COLOR OR
WARNING IRRITATION TO THE SKIN AND EYES.
Cement polymer or freshly mixed concrete may..p sg skin. injury., Avoid contact. with.
ADDITIONAL WATER ADDED TO THIS
SURFACE DISCOLORATION
skin and Wash exposed skin areas promptly wilth'iwater: If any cement powder or
CONCRETE WILL REDUCE ITS STRENGTH
mixture gets into eyes, rinse immediately and. repeatedly with water and get prompt.
medical attention. Keep children away from cementpowder and ail freshly mixed
AND. DURABILITYANY WATER ADDED IS
BATCH TIME
4 ~
cement products.
AT.Cl1SUMER'S,.OVyN:RISK
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PLAN
TICKET# ORDER_#
TRUCK #
LOAD SIZE
.ate
MIX
SLUMP DATE
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PROJECT#
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INSTRUCTIONS
TIME DUE
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SIGNATURE
OR RECEIPT - CONCRETE
AND ACKNOWLEDGEMENT
OF HAZARD
WARNING
asc I . oncre Company will no assume a r P or any. props damage or,any SUB -TOTAL
i pritnt.damage r oliverit�•tieyond the curb line.
TAX
AUTHORIZED BY
SHIPMENT SUBJECT TO CONDITIONS ON REVERSE SIDE. TOTAL
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