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t <br /> ENVIRONMENTAL SERViGES <br /> sly VOICE / ALFIRJOWATION FOR CREDF CARD BILLING <br /> Date: 3 124 OV 1`2 OV 10 9 <br /> To: Clean Harbors Environmental Service W 2121415 <br /> Fax: SA000046 <br /> Phone: 209-460-1600 <br /> From: Name:yee tantiyavarong Account Number: <br /> Company. _ amberland composite Telephone: <br /> Mailing Address:_- 3632 duck creek dr build. F Fax:209-460-1 611 <br /> City I State: Stockton Ca Zip Code., 95215 <br /> This is authormatiori to pay the fol;owing Clean Harbors invoices: <br /> Invoice Number Amount Date <br /> bate te Invoice Number Amount <br /> 3-20-09 188.00 <br /> 3559dfLlMatll(,Ipounds ati.60per pound. <br /> Flamable solid material <br /> Total Charges to be applied to credit card will be for the following amount: <br /> VISA MASTERCARD AMERICAN EXPRESS INVOICE CHECK <br /> PIN# CHECK# <br /> No Yes <br /> If yes, what is the amount? <br /> Name as it appears on Card: V Tantiyavarong <br /> Company Name: Amberland composite <br /> Card Billing Address: 2216 ceynowa In <br /> San Jose, Ca 96121 <br /> Credit Card Number: <br /> Card Authorization Date. A 20- <br /> Authorization Signature: V <br /> - <br /> RETURN RECEIPT BY. FAX U.S MAIL <br />