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1301 Gervais Street-Sure 300 DUNS NO. 05397-6551 FED.ID NO. 752178928CUSTOMER <br /> Columbia,South Carolina 29201 FOR SERVICE CALL BRANCH MANAGER DOC.EXP. scHEDutEu scHEouLEo <br /> a item. CUSTOMER NO. SERVEEWEEK TERRRORv , <br /> CR <br /> U _ 7 f S 09-545-1011 ERRY VANBERGEN O� 000510407 <br /> CREDn PREVIOUS BALANCE <br /> U �R <br /> T P� RA m- <br /> TME SNESS CHAIN WOMw SVC.PIC PROD.PIC <br /> O . <br /> M • LOCATION TAX EXEMPTION NO. <br /> E <br /> R 718501 <br /> SER CE D TE ISALESREPNO. CUSTOMER P.O.NUMBER I CUSTOMER PHONE# TAX CODE IHANDLING <br /> CODE AssocWADE. SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> ` <br /> 7 <br /> DEPT SERMCE/ bLhIAL DUAN. CHARGE SALES TOTAL WASTE SOLVENT/DRUMS CC SERVICE sEmEM sa�elrz Iw. PROMO MSOS <br /> PRODUCT NUMBER NIT PRICE TAX CHARGE MIN. CLEAN coM SK DOT TQM INEO(SHINmAjmain WDE NO. GRIB <br /> 1 ❑ <br /> 2 ❑ <br /> 3 ❑ <br /> 4 ❑ <br /> 5 � ❑ <br /> 6 ❑ <br /> 7 ❑ <br /> 9 ❑ <br /> 9 ❑ <br /> 10 ❑ <br /> 11 ❑ <br /> 12 ❑ <br /> CHECK GWD MR GECNS NPLACE YES 1MGHDE PRDPFALYGRDDNDEp VES HD <br /> TOTAL-SERVICE/PRODUCTS R 00APPROPRMTE "NNE CDNDITUN ❑ ❑ AND LEGIBLE ❑ ❑ 11 El ~ <br /> BOXES 6CUANUMM RISIR1 UNN Low PHCNE MT,STCxm Z <br /> ❑ W <br /> USEPA TRANSPORTER:1 ID NO. USEPA TRANSPORTER 2EWE 7iENERATOR USEFSAID NO. I GENERATOR STATE ID NO: ~ IAMPp55FMBLY ❑ ❑ EHEC" El El MEDEDTDKACWNE 1:1IMCLMING ❑ ❑ a g <br /> SCR000075150 coxom6x Gln MGSTRx ❑ ❑ Q <br /> 11.US DOT DESCRIPTOR INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID. 12.co NNERS 19. TUTAL 14.UNT SKDOTNUWM I cm F THAT MY TOT& <br /> ( ) S 6 O S WASTE STREAMS ARE WnFIN LV <br /> ONE OF THE FOLLDVANG <br /> CATEEMIES. <br /> A. aro2zo LBs.IMONT p <br /> Z <br /> NI N.5 Z <br /> B. 22n USE.TO 2,2DO WSMONTH a <br /> INITIALS LU <br /> C' GROVER THAN 2=tBSJTARM a, <br /> to <br /> D. INEMIS Q <br /> DESIGNATED FACILITY NAME AND ADDRESS SAFETY-KLEEN SYSTEMS, NC. I01tim"THAT NOMATERMCHANGE HAS OCCURRED USAEPAIDNO. z <br /> EITHER w THE MH TERISTICS OF TIE WA&TE a D <br /> M� OR THE PROCESS GENE THE STATE ID NOERALS. . W a <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT T0: �... AGREE ro PAY THE ABOVE CHARGES AND To BE eouNo ar THE TERMS AND TOTAL CHARGE I V <br /> U <br /> CHECK NUMBER CONomMS SET FORT ABOVE AND M THE REVERSE S1DE OF THIS DOCUMENT. <br /> ❑TOOAM69E1MCEISNE -.. PLEASE CHMGE NY ACCOUNT FOR THIS TRNN9A M UNLESS OTHENNASE (FROM ABOVET �Q <br /> INDICATED IN THE PAYMENT RECEIVED SECTOR.THE INDNIDIIAL SH3WNG THIS WASTE MIN, a <br /> ❑SIU Ba"UCE As meows LDR MESSAG DOCUMENr 49 WLY AUIHOPo2EDro9MN MID BMD CUSTOMEP TOITSIETMb. (FROM ABOVE) UU <br /> INVOICE# AMOUNTS INVOICE# AMOUNTS <br /> TOTAL DUE <br /> PREVIOUS __..i. . MANIFEST CODE SEG# DO NOT WRffE IN THEAREA BELOW <br /> CARD NO Print Customer Name <br /> CREDIT CARD NO. AMEX DEP.DATE �+' Y M000510407 <br /> VISAIN THE EVENT OF AN <br /> MCEMERGENCY CALL ByiF/ `�� 024148 <br /> CUSTOMER REFERENCE Cwtom%fAutho presendNe �` <br /> INF[TRMATiDN '1 rwo nnucruurr nnurriul pro nu rur nr,ivnnn mnc <br />