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5400 Legacy DriVB,Cluster 11,B3 800-669-5]40 DUNS NO. OS-39T-5551 FED.ID NO. 395D910019 CUSTOMER <br /> LcML1IED SCHEDULED <br /> Plano,Texas 75024 wwwsafety-kleeacom -;��/i FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SERVICE WEEK reRRIroRY <br /> SB flflA. CUSTOMER N0. - <br /> 209-545-101 FtU&EM MARTINEZ 07 MOd4271929 <br /> 1 CcOREDnE PREVIOUS BALANCE <br /> D -BAL. DAV <br /> BUSINESS CHAIN COUNTY SVC.P/C PROD.P/C <br /> • j 'r .�.� I¢, J n7 Pf LOCATION TAX EXEMPTION NO. <br /> A <br /> �� ccLC 20 718501 <br /> SERVICE DATE ISALES REP NO I CUSTOMER P.O.NUMBER E#_,CUSTOMER PHONTAX CODE HIMlouNc ^ c SERVICE TAX CO.M.S.TAX PROp11CT TAX <br /> CODE CODE <br /> SERVICE/ S E R I A REMARKS/ SALES TOTAL WASTE SOLVENT/DRUMS SERVICE CHANGE cw•Ls Nv. PROMO MSEN <br /> DEPT DUAN. CHARGE CC sERWCE TERM YH.MLf CODE NO. GIVEN <br /> PRODUCT UNIT PRICE TAX CHARGE MIN. LEANsPENT Ne, SK DOT mwm <br /> El <br /> El <br /> El <br /> CHECK GOOD POOR DECALS IN PLACE YES NO MACMNE PRCPEPLYGPWNOED YES NO <br /> TOTAL-SERVICE/PRODUCTS x APPROPRwre MACHENE COHODION ❑ ❑ AND LEGIBLE ❑ ❑.. LOCAL PHONE No.SRCKER ❑ ❑ Z <br /> BOXES &CLEANINESS HISINE LINKAFFIXED TO MACHINE <br /> WSTmjXD ❑ ❑ ❑ ❑ W <br /> USEPA TRANSPORTER I ID NO. USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO., LAMP ASSEMBLY ❑ ❑ EMERGENCYCLOMNG SPEHTSOLVENTMEETS ❑ ❑ <br /> CONDITION ❑ ❑ ACCEPTANCE CRITERIA <br /> T XR 00 00 5 0 9 3 0 �E- GP L o UNOBSTRUCTED 0 <br /> 12.CONTAINERS 13. TOTAL 14.UNIT SK DOT NUMBER 51630� CERTIFY THAT MY TOTAL W <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) No. TWE aunrvrrtv wr oL ASTE smEAMs ARE WITHIN <br /> ONE OF THE FOLLOWING <br /> e A ` �fl I�C =.��, r / {' / " CATEGORIES. <br /> fes! /". 9 P 7f (J C. DT0220 LBS MONTH Z <br /> r •. r INITT4la Y <br /> 220 LBS.T02200 LBS IMONIH Q <br /> INITMIS W <br /> GREATER MAN 2,200 LBSMONTN. Q� <br /> ALS n� <br /> DESIGNATED FACILITY NAME AND ADDRESS r +^- USA EPA ID N0. <m <br /> {y.m`Y{pY-yt_}.+,yL...e+_t>•R rt1 L'_;�r ...�1. f CERTIFY THAT NO MATEAWL CHANGE HAS OCCURRED <br /> l"1T3 44iTL T.i'i�'�Ti 1"83'3Y .1 EITHER IN THE CHARACTERISTICS OF THE WASTE _ a,, <br /> MATERIALSSTEA OR IN THE PROCESS GENERATING THE STATE ID NO. ( fi % y T 2 W <br /> F' ^ t --� �� f-} WASTE MATERIALS. <br /> CASH TOTALflECEIVED APPLY PAVMENTTO: 'MANIFEST NO. Um <br /> ❑. I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE <br /> COMMONS SET FORTH ABOVE AND G4 THE REVERSE SIDE OF THIS DOCUMENT (FROM ABOVE) �¢ <br /> CHECK NUMBER 1 HARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br /> ❑TODAY'S SERVICE541f / a PLEASE CINDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS WASTE MIN. :K; _s W a <br /> ❑PREVDDS BALINCE AGfOLLOWs UDR MESSAGE D00.1MENTIS DULY AUTHOPoZEDTO SIGNMD BIND CUSTOMER TOIISTERMS. (FROM ABOVE) (n <br /> INVOICE# AMOUNTS INVOICE IF AMOUNT$ "R�e'mmcP4A Ne1•tleebpremM�walw as poPwNa�neo.L.a.xm,�w�a wlmaNa=w=r <br /> wmm[pgYaHppflgaNbimvQegmWagheM.i.a.+wo,4aLI»Isw�m®mm�.<wwa� TOTAL DUE <br /> CFIR <br /> REDRUy NIFEST CODE SEC# --j am+ Y �� t� � DO NOT WRITE IN THE AREA BELOW'— <br /> RARDN L 4 Pn //n usomerN�Y � �— MdO4271929 <br /> CREDIT CARD NO. AMEX EXP.GATE <br /> VISA f� 029381 <br /> AM By: <br /> '4 MC <br /> Custarn FSA hwizeG epresentat e <br />