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2600 North Central Expressway, Suite 200 800-669-5740 DUNS NO 05-3976551 FED ID NO 396090019 CUSTOMER <br />CARE. SCHEDULED SCHEDULED <br />w <br />Richardson, TX 75080 ww.safety-kleen.com FOR SERVICE CALL BRANCH MANAGER DOC EXP. SERVICE yYEEK I TERRITORY <br />' <br />q. CUSTOMER NO. <br />�:�d:rL,4`.�i1iGi1 �t .;i/,e't� <br />1LI `7 CREDICOOT PREVIOUS BALANCE OVER ' ] DAY <br />LC1J ._ DE101 190 <br />CUS0F OUTERT��pCOba California Specialty Cheese CHAIN PROD. RC <br />SEGCOUNTY <br />Ai r•por-t Way 1.4253 S Airport Way <br />• • LOCATION TAX EXEMPTION NO. <br />SERVICE DATE SALES REP N0. CUSTOMER P.O. NUMBER I CUSTOMER PHONE # TAX CODE DATE EQPT/PROD ORDERED SERVICE TAX C.O.M.S. TAX I PRODUCT TAX <br />DEPT SERVICE/ REMARKS/ SALES TOTAL WASTE SOLVENTDRUMS CC SERVICE <br />ERM o r PROMO <br />SERVIA sC <br />PRODUCT UNIT PRICE QUAN. CHARGE TAX CHARGE MIN. '6` <br />�,,.,- SK DOT TERM SERVy TERMi CODE NO. <br />GIVEN <br />❑ <br />i <br />❑ <br />I <br />❑ <br />I <br />❑ <br />❑ <br />E. <br />TOTAL-SERVICE/PRODUCTS APPRHOPRnTL roan Poon Yes NO YES No <br />DECALS IN <br />❑ ❑ MACHINE PROPERLY GROUNDED ❑ ❑ <br />F <br />LEGIBLE <br />BOXES MACHINE CONDITION ❑ ❑ AND LEGIBLE LOCAL PHONE NO. STICKER <br />Z <br />8 CLEANLINESS FUSIBLE L14K E ❑ AFFIXED TO MACHINE ❑ <br />W <br />-4 INSTAD <br />SPENTSOLVENTET <br />USEPA TRANSPORTER 1 ID NO. USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. LAMP ASSEMBLY ❑ ❑ CLOSING <br />ETAN <br />EMERGENCY El 112 <br />CONDITION OF UD UNOBSTRUCTED o ❑ CR E <br />0 <br />11 US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.) <br />12. CON <br />N <br />AINERS <br />TYPE <br />13. TOTAL <br />TITY <br />14.UNrT <br />WTNV L <br />SKDOTNUMBER <br />I CERTIFY THAT MY TOTAL <br />WASTE STREAMS ARE WITHIN <br />W <br />J <br />ONE OF THE FOLLOWING <br />CATEGORIES. <br />0 TO 220 LES iMONTH <br />I <br />O <br />Z <br />INITIALS <br />Y <br />220 LBS. TO 2.200 LBS IMONTH <br />Q <br />W <br />INITIALS <br />GREATER THAN 2.200 LBS /MONTH <br />Q� <br />C' <br />INITIALS <br />Q U <br />Q <br />DESIGNATED FACILITY NAME AND ADDRESS <br />I CERTIFY THAT NO MATERIAL CHANGE HAS OCCURRED USA EPA ID <br />NO. <br />Z q <br />Q <br />EITHER IN THE CHARACTERISTICS OF THE WASTE <br />c! <br />W <br />MATERIALS OR IN THE PROCESS GENERATING THE STATE ID NO. <br />WASTE MATERIALS <br />I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND <br />CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. <br />CASH ❑ <br />TOTAL RECEIVED <br />APPLY PAYMENT TO: <br />MANIFEST NO. <br />TOTAL CHARGE <br />(FROM ABOVE) <br />- ^ A/ <br />> I- <br />G <br />CHECK NUMBER <br />CC <br />❑ TODAYSSERVICE/SALE <br />PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br />J <br />INDICATED IN THE PAYMENT RECEIVED SECTION THE INDNIDUAL SGNING THIS <br />WASTE MIN. <br />W <br />LDR MESSAGE <br />V, 11 <br />El PItLV10U$BALANCE AS FOLLOWS <br />DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS <br />Th1"m ry nn ItM.BPrtnWMO mm�r... P.a "a e# . P. .G.4 mr..a. a i.GWo — n <br />nw.ca,aua, c. vY"Paumo.[coenp. n, e.Pd w <br />/ r <br />VISA <br />(FROM ABOVE) <br />.. ' <br />(n <br />TN <br />DE IN INVOICE F AMOUNT $ INVOICE At AMOUNTS <br />TOTAL DUE <br />PREVIOUS <br />MANIFEST CODE <br />DO NOT WRITE IN THE AREA BELOW <br />CREDIT y <br />4 <br />-CARD No <br />Print Custoniet Name <br />��`.. <br />AME% <br />VISA <br />IN THE EVENT OF <br />M <br />EMERGENCY CALL <br />BY <br />CUSTOMER REFERENCE <br />Customers Authorized Representative <br />THIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br />INFORMATION1-800-468-1760 <br />