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EDULED <br /> 5400 Legacy Drive,Cluster II,83 800-669-5740 SCHEDULED WED scRFUTORY <br /> AS Plano,Texas 75024 W W W.safety-kleen.com v; FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SERVICE WEEK TERRITORr <br /> WAI�'Allll. CUSTOMER NO. <br /> CREDIT PREVIOUS BALANCE SAL OVER 600AY5 <br /> ' CODE <br /> +'e :�•�"' aUOUTER <br /> TYPE� CHAIN caurvtt SVC.PIC PROD.PIC <br /> Alk! <br /> LOCATION +TAX EXEMPTION NUMBER <br /> ca <br /> HANDLING ASSOC, SERVICE TAX QO.M.S.TAX PRODUCT TAX <br /> SERVICE DATE SALES REP NO. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODE CODE CODE <br /> .. ,'• t� "? 1� �I�G� / ,i(.�9 ...:�)7� CHANGE - - <br /> SALES TOTAL CHLORINE TEST PESULTS SK DOT SERVICE cx"xc` PROMO <br /> DEPT SERVICE/ CC SERmCE TERM scxmle NO RELEASE NO. <br /> PRODUCT UNIT PRICE QUANTITY CHARGE TAX CHARGE xuoaexreslee cH�oaoTecT NUMBER TERM <br /> PFSS fNl XESULis PPIFI T(SIFASIXIIIPts z. <br /> 3 Upb 1.4 40 <br /> a e <br /> / �° ci — ❑ ❑ <br /> El El <br /> 6 <br /> 7 <br /> 8 ❑ ❑ 7 <br /> 9 TANK ••' DATE / ®/O`AJ� <br /> TOTAL-SERVICE/PRODUCTS '? �� Y 0 APAcITv <br /> a IbQ X dna t ��1�� <br /> •. • • :• - • MANIFEST NO. USEPA TRANSPORTER ID NO.. 1 q <br /> l PE <br /> , INT NAM SIG TTI q <br /> GENERATOR'. VEHICLE OTHER I NO PREOUAL REQUIRED,NO HALOGEN TEST DATE <br /> HAZARDOUS WASTE FLUIDS NON-VEHICLE nC�t.� `) "` '��O <br /> HAZARDOUS <br /> WAST ONLY FLUIDS 2 NO PREOUAL REQUIRED,HALOGEN TEST AT PICK-UP 1- <br /> 3PREOUALREQUIRED,NOHALOGENTEST GENERATOR USEPA ION <br /> GENERATOR STATE ID NO. f. <br /> CESQG El E-13 4 PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP X --- a <br /> SQG/LQG ❑2 ❑4 'REFER TO REVERSE 9a {` PRINT NAME SIGNATURE <br /> 12.CONTNNERS 13. TOTAL 1L.UNIT SKODTNUMSER <br /> lnr - r <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) N . AN � pA Z <br /> 04CL Wat nk., Slu �c)�haa� usnot /fit 5 S A j W a fu; .` ILE!LU <br /> (,w <br /> R <br /> J <br /> Z <br /> OY <br /> OU <br /> LU <br /> INTERMEDIATE FACILITY NAME AND ADDRESS USA EPA ID IJO. E t LU 1 LU <br /> IrT, f'" (' ('I STATE ID NO. —J <br /> }} J <br /> )Ike CI i Eos � �4- <br /> CASH ❑ TOTAL RECEIVED-_ APPLY PAYkENT TO: _ CHARGE MV ACCOUNT FOR THISi TRANSACTION LNIESS-OTHERWISE - TOTALDUE ),�.H'F i O N <br /> .-.----' - INDICATED IN THE PAYMENT RECENED SECTION. f -,�.i-Y.-_ <br /> CHECK NUMBER CEes e_._ - LnrexSST.aysw-PPEI <br /> -.--_ e' x.reoomuon e�cue'„3wu,e q#-cero,eRugarm ame <br /> ❑ PREVIOUS BAUXCE AS FOLLOWS U.S.Emmonmeem',Pm,ttvon Agexy eMmeUS.OgeNneR OlTwnpontllm <br /> INVOICE# AMOUNTS INVOICE# AMOUNT$ ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS <br /> PREVIOUS .. _ N01CUM rint iNT ARE INCORPORATED HEEWITi MADE APART HEREOF. <br /> MANIFEST CODE SEC# A <br /> CREDIT <br /> AR <br /> CREDIT CARD NO. AMAX EXP.DATE <br /> .. VISA OF <br /> X T,-. <br /> MCEMERGENCY CALLGENEMTORISHIPPER BESIGNATEO REPRESEMAI WE eIGNATURE <br /> CUSTOMER REFERENCE1.800-468-1760(24 ftours) <br /> INFORMATION <br />