- Credit Card Refund Request Form -

Location: Torrance Original Sales Date: 4/2/2016

Total Original Amount:
Mgr / SV Name: Mary/ Ray (including tip) $ 81.64
Receipt Check#:
Date: 4/8/2016 (If known) 930042
Food Refund Tip Refund Credit Card Last 4 Digit #:
Amount: $81.64 Amount: $0.00 (If known) 1487

Refund Reason: ❑ Double Charge ❑ Overcharge X❑ Other (Please explain below )

(Reason): Customer and 2 guests suffered extremely bad food poisoning after dining at TR on 4/2/16

Customer Agreed? X❑ Yes ❑ No

«Attach Signed Credit Card Receipt (if available) »

L-Kaku Tor Tar ce
(310)325-1431
24E 31 CrensheN P lvd ,
Tc r rance, Cl' 9C E05
'TE 1 : 310-32E -1437

Se r : Esme re Ida DOB: 04/02/20'5

08:35 Ph 04/02/20'6
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SALE

Visa 2097167
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Please fill out the form and atk__

/ fax to 310-532-0236.
then email to Accountinq@qvu - kaku.com and it@gyu-kaku.com