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1301 Gervais Street-Suite 300 y'xs DUNS N0, 05-397-6551 FED.ID NO. 396090019 %duo 1 VIVICI"i <br /> Columbia,South Carolina 29201 � FOR SERVICE CALL BRANCH MANAGER DOC.EXP, SCHEDULED SCHEDULED <br /> BIIf61l1. CUSTOMER NO. \- SERVICE WEEK TERRITORY <br /> 209-5,45-1011 RALPH TORRES 03 MQC,1836917 <br /> C _ 7- �'— �`/ CODE PREVIOUS BALANCE AL. 0 <br /> U <br /> S >U?E� <br /> T BUSINESS OUTER <br /> TYPE CHAIN SVC.P/C PROD.P/C <br /> O � S"f ,( ��i� �,f♦,{��" 7 COUNTY <br /> E • / O6V�a�i �F` 9-J � • LOCATION TAX EXEMPTION NO, <br /> R 1 1718501 <br /> S RVICE DAT4 JS5,ES' O, I CUSTOMER P.O.NUMBERCUSTOMER PHONE# TAX CODE HANDLING ASS G.CODE CODE SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> _. T1 0 7' V <br /> SERVICE/ SERIAL. R k1 �( ? CHANGE 11ANGE INV. PROMO MSDS <br /> DEPTDUAN. CHARGE SALES TOTAL WASTE SOLVENT/ RUMS CC SERVICE <br /> PRODUCT IT SERVICETERM SCM.DATE <br /> I`IUMBE R UN � C TAX CHARGE MIN. CLEAN SPENT �oNT SK DOT TERM EEKS INITIAL by wwl CODE NO. GIVEN <br /> 100 <br /> 2 (� .� (� Tt.. 1�S )l[ 3� `d aC., r GAG• 7 30 lt'�..� ❑ <br /> El <br /> 3 ❑ <br /> 4 <br /> 5 ❑ <br /> 6 ❑ <br /> 8 <br /> 9 ❑ <br /> 10 <br /> 11 ❑, <br /> 12 ❑ <br /> CHECK GOOD POOR VES NO <br /> TOTAL-SERVICE/PRODUCTS APPROPRIATE DECALS IN C ❑ ❑ MACHINE PROPERLY GROUNDED ❑0 Z <br /> C E LAE YES N <br /> MACHINE CONDITION ❑ ❑ AND LEGIBLE LOCAL PHONE N0.STICKER ❑ <br /> BOXES g CLEANLINESS FUSIBLE LINK ❑ ❑ AFFIXED TO MACHINE ❑ ❑ W <br /> USEEPATRaNSPOFITR 1IDNQ, USEEPI-TRANSPORTER 2:ID NQ. GENERATOR USE PA IDN .�; , ,GHNERATOR�STATE-ID{NO. LAMP ASSEMBLY INsrAueO <br /> EETS <br /> T e C y� f G rr CONDITION ❑ ❑ EMERGENCY CLOSING ❑ ❑ ACCEPTANCE CRISPENT SOLVENT TERIA ❑ ❑ Ue <br /> 1 X R Q Q J O J.';U `, d•� OF LID UNOBSTRUCTED <br /> 11.US DOT DESCRIPTION (INCLUDING PROP R SHIPPING NAME,HAZARD CLASS,AND ID. 12.CONTAINERS 13. TOTAL 1a.UNIT CERTIFY THAT MY TOTAL <br /> N t NO. E QUANTITY SK DOT NUMBER 1 r� WASTE STREAMS ARE WITHIN Uj <br /> J,p/'` \- f �J 1 J0v 1) A �lT y' JC�, / / ,^ ONE OF THE FOLLOWING <br /> �. �fY V r.... u -I,Ji7T f /-I C?�i f(.-�(J�.� ,�L� / C'(J��../ /`,4" l G f� 0TO220 CATEGOLIBS./ NTH O <br /> :ARZ/ Z <br /> INITIAL X <br /> 3 220 LBS.TO 2,200 LBS./MONTH V <br /> Q <br /> �. INITIALS W <br /> GREATER THAN 2,200 LBS,MIONTHCn J <br /> aC <br /> INC. <br /> INITIALS 0 C <br /> DESIGNATED FACILITY NAME AND ADDRESS S Af E T Y—K L E E N SYSTEMS, INC. I CERTIFY THAT NO MATERIAL CHANGE HAB OCCURRED USA A ID NO. Z s <br /> EITHER IN THE CHARACTERISTICS OF THE WASTE Q C <br /> MATERIALS RI IN THE PROCESS GENERATING THE STATELI D NO. <br /> � WASTE MATERIALS. � {j.t 4 <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: ,{ ;o/q(Aj((` AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE U C <br /> CHECK NUMBER CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) ;C <br /> ❑ <br /> TODAY'S SERVICE/SALE - � �/ PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br /> ❑ PREVIOUS BALANCE AS FOLLOWS INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS WASTE MIN. CCC <br /> LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE) N C <br /> INVOICE# AMOUNT$ i INVOICE# I AMOUNT$ 'Thla I,to candy tnet the atwe-named malerlela are properly cleee tied,packaged,marked and labeled,and are In <br /> e proper condition to,h—portatlon ettprdi to the applicable regulations of the Department of Tranaportet,on' <br /> PREVIOUS MANIFEST CO E SEO# -- r- TOTAL DUE ,� ej <br /> re <br /> f✓ <br /> CREDIT _ /,)c)&l' � G✓ z rt. <br /> C RD N w I r 1 1 DO NOT WRITE IN THE AREA BELOW <br /> Print Customer Name <br /> CREDr�CARD'N, . Ani :.p oaT a NI0 01 8 3 6 9 17 <br /> t By: -� 0 0 6 6 91 <br /> EMERGENCY CALL Custom s AuthoriM Representative <br />