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5400 Legacy Drive,Cluster II,B3 800-669-5740 ,-L DUNS NO. 05-397-6551 FED,ID NO. 398090019 CUSTOMER <br /> Plano,Texas 75024 wwwsafe kleen.com .p FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SCNEDUIfD sERRITORY <br /> ty- ERVICEW K TERRITORY <br /> CUSTOMER NO. <br /> 09-545-1011 7 1 004142631 <br /> cl <br /> 2 — G 7C� Z v GCODE PREVIOUS BALANCE/ �f �y� TY ` / '/`� Sy.sr-�� 1 MAY 1 1 2007 BUSINESS OUTER <br /> v / - TYPEINE CHAIN COUNTY <br /> SVC.P/C PROD.P/C <br /> M v27�� POCK /,4AI-' ENVIRONA'cNT HEALTH LOCATION TAX EXEMPTION NO. <br /> A IGC C l PERMIT/SERV <br /> SERVICE DATE ISALEpS REP�yNO. I CUSTOMER P.O.NUMBER USTOMER PHONE# TAX CODECo HAKUNUNG ABODE. SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> SERVICE/ REMARKS/ MTAXCHARGE <br /> WASTE SOLVENT/ HUMS SERVICE CHANGE cInME PROMO MEDS <br /> DEPT PRODUCT NUMBER UNIT PRICE DUAN. CHARGE MIN. CLEAN SPENr SKDO7 CC TERM SEERVICE TERM mcwE NO. GIVEN <br /> 2 jt/� 60 �, 7 TC 2C1 3�� & ❑3 Ss33«.> Ve..PAycK 3aG' -3 clj � ❑ <br /> 4 wea ❑ <br /> 5 ❑ <br /> 6 ❑ <br /> 7 ❑ <br /> " ❑ <br /> s <br /> 10 <br /> 11 <br /> 12 <br /> CHECK coon POOR YESEi NO res NO <br /> TOTAL-SERVICE/PRODUCTS r' APPROPRIATE DECALS 1NPIBLE ❑ ❑ MACHINE PROPERLY GROUNDED ❑ ❑ F <br /> MACHINE CONDITION ❑ ❑ AND LEGIBLE LOCAL PHONE NO.SICKER Z <br /> Iii BO%Es BCLMNLINESS FUSIBLE LINK <br /> ❑ ❑ AffO&O TO MACHINE ❑ ❑ W <br /> USEPA TRANSPORTER 1 ID NO, USEPA TRANSPORTER 21D NO. GENERATOR USEPA ID NO, GENERATOR STATE ID NO. UMP AssEmmy INSTALLED SPENT SOLVENT MEETS <br /> COMMON ❑ ❑ OF LID UNOBSTRUCTED <br /> ❑ ❑ AGCEWANCE CRITERIA <br /> Of LID UNOBSTRUCIEO ❑ ❑ <br /> 12.COMNNERS 13. TOTAL 1N.UNIT I GERIFT THAT MY TOTAL <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND IR.) No TYPE1VT SK DOT NUMBER WASTE STREAMS ARE WBHIN W <br /> jtjd N A{� ��Z� ��S ���r '� _ 'ry j ONE OF THE FOLLOWING J <br /> /` / /'Y I <br /> PIES <br /> DTO220LBBM. ONTH 5zA. O <br /> M �i <br /> B. 22OLB6.T9220OLBSN U <br /> N <br /> AINRIALS W <br /> C. GREATER THAN 2,200 USE MONTH Q <br /> D. INITMLS cc <br /> DESIGNATED FACILITY NAME AND ADDRESS — i • - I CERTIFY THAT NO MATERIAL CHANGE HAS OCCURREDUSA EPA ID N0. Z� <br /> EITHER IN THE CHARACTERISTICS OF THE WASTE a¢ <br /> MATERIALS OR IN THE PROCESS GENERATING THE STATE ID NO. Wit- <br /> WASTE MATERIALS. V m <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 /> CHECK NUMBER PLEASE CONDITICHFORTHS GET COVE AND ON E <br /> ARGE MY ACCOUNT FORT STRANSACTION UNF THIS LESS SS OOTHERWI E(UMENT FROM ABOVE) >� <br /> E]TODAY55ERVICE/sALE <br /> • ❑PREY19U5 BALGNCEAS fOLLGWSINDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL STONING THIS WASTE MIN. W a <br /> LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SON AND END CUSTOMER TOITS TERMS. (FROM ABOVE) N <br /> INVOICE AMOUNT$ INVOICE AMOUNT$ 'PS°°P./B..�b^fa°�°NNm.°Pm..emn...e«.��.�°e nu�P'Y.fB�rN�PP..NM.�N®nea.wM�a.°wm..xee sne mew.eaw°e 1° <br /> TOT <br /> PREVIOUS MANT A• . AL DUE 2/C <br /> SED# <br /> CREDIT ti / DO NOT WRITE IN THE AREA BELOW <br /> !� Gr . <br /> V PriMC�usID Name + <br /> CREDIT CARP N0. AMEX EXP.DATE M004142631 <br /> VISA IN THE EVENT OF AN 026013 <br /> I I I <br /> EMERGENCY •" By: <br /> CVstomars AutNoriztl RepresenlatHe <br /> CUSTOMER REFERENCE 1-800-468-1760(24 hours) <br /> THIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br /> INFORMATION c.. <br />