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5400 Legacy Drive,Cluster II,B3 800-669-5740HEFERENCE NU MEER <br /> Plano,Texas 75024 www.safety-kleen.COm PLACEMENT FORM FORSERVICE CPLL ;al_F'ii 1 CJJI? !V R.MANAGER -"•r ,, <br /> - C7 <br /> DUNS NO.05-397-6551 FED.ID NO.396090019 <br /> NAME TITLE SIGN Z <br /> GENERATOR LOCATION tN BILL TO(IF DIFFERENT FROM LOCATION) 1. A <br /> NAME <br /> 2. <br /> 'DE UV ADDRESS RESS <br /> f/ <br /> LOCATION SIC CODE <br /> INFO V TIONIATTENTION LINE ATTENTIO L TATE US10MECHAIN N;SOCIATI SVC.P/C PROD.I'/C <br /> MEp TAXCODE <br /> SALES TAX EXEMPTION NUMBER <br /> TM M <br /> DATE PLACED ISALES REP NO. ❑BLANKET ❑TEMPORARY CUSTOMER PHONE NO. DATE EQPT/PROD ORDERED SERVICE TAX C.O.M.S.1 AX PRODUCT TAX <br /> t 1 CUSTOMER'S qq y <br /> P.O.NUMBER <br /> DEPT SERVICE/ SERIAL REMARKS/UNIT PRICE QUAN. CHARGE SALES TOTAL SOLVENT/DRUMS SERVICE - -� va /III INV, PROMO MSDS <br /> PRODUCT NUMBER TAX CHARGE uI S S:N TERM v WSW' d,l ry ""' "xx NO. NO. GIVEN <br /> 2 r El <br /> 3 45 (,, r [_ <br /> 6 ❑ <br /> 7 11 <br /> TOTAL-SERVICE/PRODUCTS ��/ RE FUSED SERVICE EXPLAIN * (1)NEWAPPUCAION <br /> 7 (2)REPLACE DEFECTIVE MACHINE <br /> PLACEMENT(3I REPLACE COMPETITIVE MACHINE <br /> USED ;T!i 1- USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. CODES (4)REP ACE HOME MADE VAT. <br /> /� t :::14'MQ (5)ADDITIONALMACHINE <br /> p 12 CONTAINERS 13. TOTAL 14.UNIT I CERTIFY THAT MY TOTAL <br /> G, R Ep S IApING 6ME NAI�DC'pCc DID. eKDOTNureBE9:- <br /> 3,t,LJlS QQT-DESCRIPTI9Na:41bS,'!.l�Q1�...P.Q,7 '7 F(T N, ._ Y q jti N. )" "- ''' -• NO TYPE OUANTI IY YJTIVOL � 'T '- WASTE STREAMS ARE WITHIN <br /> -, ... .(....I ,(' —,;)..r:I t71. 'i�.� •t 'I�'-'i t . CNE OF HE FOLLOWING <br /> CATEGORIES. <br /> 0 TO 220 LBS/MONTH <br /> A. <br /> INITIALS <br /> B. 220 LBS.TO 1,200 LBS.IMONT' <br /> r INITIAIS O <br /> C. G, GREATER THAN 2.200LBS.IMONTH o <br /> [-r __ i [ <br /> D. ii�')1 CEI�Y-"t�l_I:.,G.'�I ,':I�i3 1 L_I" I INITIALS <br /> O <br /> DESIGNATED FACILITY NAME AND ADDRESS USA EPA ID NO <br /> STATE ID NO. `.IJ _' `:/ O <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: MANIFEST NO. I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE <br /> CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) <br /> CHECK NUMBER ❑TODAY'S SERVICElSALE +,'j 'y_,) S k PLEASE CHARGE MV ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br /> INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS TOTAL DUE <br /> ❑PREV OUS BALANCE <br /> AS FOL OWS LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. <br /> • •Tr„s e ro uwlr wl w aw.c-�n:�R., �:.a,e wwe^r c�lr.Paaaye4.rtwkna aim Ldu4wl.n.xl a.o,n <br /> INVOICE# AMOUNT$ INVOICE AMOUNTS �,b„Iia,,, m„��ro�,pyo,�yo,,,yu,�o�a,m�wdT,�:P.w,a,,.• DO NO WRITE IN = BEL <br /> � r <br /> PREVIOUS MANIFEST CODE SEQ <br /> CREDIT <br /> CARD NO Print Customer Name <br /> CREDIT CARD NO. AMEX 'DATE' - <br /> VISA • 'Y. i i/j t <br /> MCEMERGENCY CALL I BY:Customer's Authorized'Representative.^! <br /> CUSTOMER REFERENCE <br /> INFORMATION 'I I •' 'I THIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br />