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5400 Legacy DONE,Cluster II,83 800-6169-5]40 DUNS NO. 057-BM1 FEU.ID NO. <br /> Plano,Te%es 75024 WWW.safe kleen.com �01a t.UJI VIVICYi <br /> N- FOR SERVICE CALL BRANCH MANAGERT DOC,EXP, SCHEDULED SCHEDULED <br /> YMIIINM. CUSTOMER NO. sEmlcE ""TORY <br /> C 09-545-1011 RUBEN MARTINEZ 04 M00239528; <br /> U6 () (' — S v cCOD PREVIOUS BALANCEAll 60 <br /> S CHAIN Dia SVC.P/C PROD.P <br /> T <br /> O TYPE COUNTY <br /> M <br /> E • LOCATION TAX EXEMPTION NO. <br /> R 718501 <br /> SERVICE DATE ISALES REP N0. I CUSTOMER P.O.NUMBER I CUSTOMER PHONE M I TAX CODEDUNO SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> DEPT SERVICE/ SALES TOTAL WASTE SOLVENT/DRUMS SERVICE CHARGE axxlE NV PROMO M <br /> PRODUCT NUMBER N BNITP CE Off' CHARGE TAX CHARGE MIN. TAN SPENT '� CC TERM sERVTCEreRM Sa. caDE NO. GI <br /> SK DOT <br /> 1 <br /> 2 2Z SS [ <br /> ell <br /> 4 <br /> 5 [ <br /> 6 <br /> I 1A7 <br /> 9 <br /> 10 <br /> 11 [ <br /> 12 <br /> CHECK GOES POOR YES NO YES NO <br /> TOTAL-SERVICE/PRODUCTS -� • S� APPROPWATE DECALS IN PLACE ❑ ❑ MPCHINEPROPEALYGROUNDED ❑ ❑ f <br /> BOXES WHINE CONCIOON ANO LEGMLE <br /> ❑ LOCAL PHONE NO.SICKER Z <br /> A CLFANUNFSS RISIBLE UNIX ❑ ❑ AFFIXED TO MACHINE ❑ ❑ M <br /> USEPA TRANSPORTER I ID NO.. USEPATRANSPORTER2AD NO, GENERATORUSEPAIDNO.. GENERATOR STATE ID NO. 'I' LAMP ASSEMBLYEl ❑ EMERGENCYCLOGNG SPENT SOLVENT WETS <br /> ROOD e-Al L7 DONAMON OF LID UNOBSTRUCTED ❑ ❑ <br /> ACCEPTANCE CRITERIA ❑ ❑ L <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND tD.) 12.CONTAINERS 1a. TOTAL 14.UNIT SKOOTNUMBEn 1 CERTIFY THAT MY TOTAL LL <br /> N . TYPE Wr L O S WASTE STA AMS ARE WITHIN <br /> ��� ^ ONE OF THE FOLLOWING <br /> V CATEGORIES. <br /> �A�7G oro zzo las C <br /> Z <br /> 3 INTwLs 1L <br /> vA� 2zD Las.To z,zDD Les .H d <br /> Z 1 NMS LL <br /> GREATER MAN 2.2W UPSAIONTH Q <br /> NRw 5 Q <br /> DESIGNATED FACILITY NAME AND ADDRESS SAFETY—KLEt <br /> S, INC. EITHER THECH4TEA CHIHGEHgSOGCflflEOUSAEPAIDNO. Z <br /> EITHER IN THE CRARACTEPISTICS OF THE WASTE Q <br /> IMTEflwte OR IN THE PROCESS GENERATING THE STATE ID NO. LL <br /> WASTE NATEFl V <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT 70: ,.H,1 % I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTALCHARGE <br /> CHECK NUMBER CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE❑TOMYS sERVmsALE PLEASE SURGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISEINDICATED IN THE PAYMENT RECEIVD SECTION.THE INDIVIDUAL SIGNING THIS WASTE MIN.❑PREWOUSBAVNCF AB FOLLOWBAGE DOCUMENTIS DULYAUTHDRIEED TO SIGN AND BIND CUSTOMER TO ITSTERMS. (FROMMOVE) NINVOICE! AMOUNTS INVOICE♦ AMOUNfTeCy C <br /> PREVIOUS SEOybb4•w, ,•�,l„NN•n�°awe.w�Mm.a„.o.P.,,,..ar,.�IPal.o„ TOTAL DUE y� }��a <br /> CREDITc�wd� `� DO NOT WRITE IN THE AREA BELOW <br /> RD NO 10 D �CUNomBr Name T� <br /> CREDR CMDNO. AMEX EXP.DATE tCw�i M002395282 <br /> IN THE EVENT FAN <br /> MFT ICA a EMERGENCY CALL By; - 029381 <br /> CUSTOMER REFERENCE atoRIAulhal2arl presan <br /> INFORMATION :1-800-468-1760 TWIQ AC9GFFAAPM CCYMTIMI IFA TYNI TNF NFVFRSP RITIF <br />