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5400 Legacy Drive,Ciu;ter 11,B3 800-669-5740 l DUNS NO. 05-397-6551 FED.ID No. 39$090019 CUSTOMER. <br /> Plano,Texas 75024 wwwsafety-ideen.com FOR SERVICE CALL I BRANCH MANAGER T DOC.EXP. SCHEDULED scHEDULED <br /> SERVICEWEEK TEFWITOaY •' ' <br /> ��. CUSTOMER NO. 09-545-1011 UBEN MARTINEZ 7 004142630 <br /> t CREDIT PREVIOUS BALANCE <br /> D 2 — (•' 1 Z -' / / CODE BAL OVER 60 D V <br /> U <br /> OUTER <br /> S /� I '•:2 i[ �y���f BUSypE� CHAIN COUNTY SVC.P/C I PROD.PIC <br /> M f/27 `/ ' "'Y L �f LOCATION TAX EXEMPTION NO. <br /> EcC�'7o lh grz� G <br /> R <br /> SERVICE DATE SALES REP N0. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODE HAND <br /> ODE G oe I SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> Y—/Uro7 <br /> °/ Int <br /> SERVICE/ REMARKS/ SALES TOTAL WASTE SOLVENT/DRUMS SERVICE CHANGE cxnxe INV. PROMO MSDS <br /> DEPT P NUMBER UNIT PRICE DUAN. CHARGE TAX CHARGE MIN. CLEANBPENT .M SKDOT CC TERM SERVICE TERM mSA cooE N0. GIVEN <br /> 1 ° <br /> 2r'.� - ❑ <br /> 3 yol�i36� 8 2 k� / "�G�l ❑ <br /> 4 •F&� Wei lAIZ 7S' yKg 2 yy _�. ,..,HBRe�P,e... ❑ <br /> 5 ° <br /> 6 <br /> 7 ° <br /> >. <br /> 9 ❑ <br />,0 ❑ <br />„ C ❑ <br />,2 El <br /> CHECK GOO MOP YES NO YES NO <br /> TOTAL-SERVICE/PRODUCTS L APPROPRIAE ❑ ° DECALS L ❑ ❑ MACHINE PROPERLY GROUNDED 1:1 ❑ F. <br /> BOXES MACHINE CONDITION AND LEGIBLEEGIBLE LOCAL PHONE NO.STICKER Z <br /> BCLEANLINESS FUSIBLE LINK ❑ ❑ AFFIDED TO MACHINE ❑ ❑ W <br /> USEPA TRANSPORTER, ID NO. USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. LAMP ABBE MeLv ❑ ❑ EMERGENCYITJUM NG SPENT sotvENrMEETs rd <br /> CONDOM OF LID UNOBSTRUCTED ❑ ❑ ACCEPTANCE CRITERIA ❑ ❑ �F <br /> US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID. tz.corvuwBRs i3. TOTAL u.urvIT cEflnFr THAT My Totu 0 <br /> /L ( �� NOI TYPE QUANTITY WT OL SK DOTNUMBEfl WASTE STREAMS ARE WITHIN W <br /> ONE .1 G e-w;5 `7�}2 {��i� V `A f t1 -/•q y CATEGORIES <br /> .HE FOLLOWING J <br /> �/1 /,/I 2 •)111 C. 06 to /�vv � 0TO 220 LBS/M0NM 50 <br /> jl/UtV /eCFp. ffQZ 4ic/Vojr L'L'Arl� /(k-Inf n /� //] INITIALS Y <br /> B. �.T S'A7.:� SOIL �. '"� �Y ����� 220 LBS.TO 2.200 L8SJMONM Q <br /> Al c A/ /ccRa Afnzan t�pvr ( • A .r7C L/1-��S i rn <br /> GNEATERTHAN2,200LBSNONTH Q <br /> a <br /> N0 <br /> D. INrruLs o <br /> DESIGNATED FACILITY NAME AND ADDRESS CERTIFY THAT No MATERIAL CHANGE HAS OCCURRED USA EPA ID NO. Z <br /> A EITHER IN THE CHARACTERISTICS OF THE WARE Q¢ <br /> Iv f Geo Al✓✓ wq AA- Nt J2 /✓ / -- WASTE MA RI IN THE PROCESS GENERATING THE STATE ID NO. VT a W <br /> WASE MATERIALS ,`m <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: MANIFEST NO. AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE V <br /> CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) >— <br /> CHECK <br /> NUMBER ❑iOMYS SERVICFJSALE �) PLEASE CHARGE W ACCOUNT FOR THIS TRANSWCTON UNLESS OMERWISE W a <br /> INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS WASTE MIN. <br /> ❑PPEV� .sERVCEASz VY LDH MESSAGE , DOCUMENT IS DULY AUTHORI2R0 TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE) O <br /> INVOICE AMOUNT$ I INVOICE AMOUNT$ P.ro a�U.a.w•mn„exes.m ae.w,w.�.m cyy <br /> F r�Q..1t J' wro. vmn,e/.,.w�Wm^roa�,n�.PpsyeH,gxNam.MNf OePMmerXmTrenygrlg:m� TOTAL DUE <br /> PREVIOUS MANIFEST CODE SED# �G� 1'/ `(/—�� GA.� DO NOT WRITE IN THE AREA BELOW <br /> CREDIT ,v V VV ( G <br /> AR N PNM Ust Name M404142630 <br /> RE RON AMEX EXP DATE <br /> VISA G � '% • ® 026013 <br /> M By: <br /> -. Customers Authorized Repreaentetive <br /> CUSTOMER REFERENCE _ 1-800-468-1760 HIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br /> INFORMATION <br />