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k' <br /> /I INVOICE / AUTHORIZATION FOR CREDIT CARD BILLING <br /> Date: 114 r77 <br /> To: Clean Harbors Environmental Service Job# <br /> Fax: <br /> Phone:761-792-5249 <br /> From: Name: Account Number: <br /> Company. Wivip (()Vn F) o Al Telephone: 20` �37—°J n7 <br /> Mailing Address: W )1 /�p (flemgn �i/ Fax: t 5b <br /> City I State: A rG i Cc, Zip Code: l YZ Z - <br /> This Is authorization to pay the following Clean Harbors invoices: <br /> Invoice Number Date Amount Invoice Number Date Amount <br /> Total Charges to be applied to credit card will be for the following amount: $ <br /> VISA MASTERCARD AMERICAN EXPRESS INVOICE CHECK <br /> PIN# CHECK# <br /> No_ Yes <br /> If yes, what is the amount?$ Z,Q 0 <br /> Name as it appears on Card: <br /> Company Name: <br /> Card Billing Address: <br /> Credit Card Number: <br /> Card Authorization Date: <br /> Authorization Signature <br /> RETURN RECEIPT BY: FAX U.S. MAIL <br />