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San <br />Ieanftbor 7850 South <br />Co- ""� <br />C, 7650 South R.A. Bridgeford St <br />° Stockton, CA 95206 <br />DMOOO-1111 11- tiE11t110ES' Telephone (209) 466-5670 <br />Fax:(209)468-5672 <br />INVOICE / AUTHORIZATION FOR CREDIT CARD BILLING <br />Date: 5/1512009 <br />To: Clean Harbors Onvironmental Service <br />Fax: <br />Phone: 781-792-5249 <br />From: Name: Robert <br />Job#: SJ2307847 <br />SA000D46 <br />Account Number: <br />Company: Collicutt Energy Services Telephone: 209-610-1544 <br />Mailing Address: 3955 Arch Rd Fax: 0 <br />City i State: Stockton Ca 95215 <br />This Is authorization to pay the following Clean Harbors Invoices: <br />Invoice Number Date Amount Invoice Number Date Amount <br />SJC 5115109 $ 12962 <br />Total Charges tp be applied to creM card will be for the following amount: <br />129.62 <br />VISA ❑ MASTERCARDO AMERICAN EXPRESS ❑ INVOICE ❑ CHECK ❑ <br />PIN#: CHECK# <br />If yes, what is the amount? $_ <br />Name as it appears on, Card: Robert Gonzalez <br />Company Name: CESI <br />Card Billing Address: 940 Riverside Parkway Suite#80 <br />West Sacramento Ca 95605 <br />Credit Card Numbec 5474 7837 0294 <br />Card Authorization date: Dec -11 <br />Authorization Signature:— <br />RETURN RECEIPT BY: FAX 0 U.S. MAIL <br />940 Riverside Parkway Sufte#80 <br />West Sacramento Ca 95605 <br />