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v� One nckn3 Way DUNS NO.05100-04M FED.ID NO.39,0090019 CUSTOMER <br /> ,gFl,Illinois 6012&7857 FOR SERVICE CALL BRANCH MANAGER DOC <br /> �a .EXP. PRIM <br /> SCHED n cn SCHEDULED <br /> CUSTOMER NO. SERwcE WEEK TERRrtoer <br /> 09-54S-1011 M9NICA SHANNON ;/;3g/99 '19—D6 'L 41I'976= <br /> c CREDIT PREVIOUS <br /> BALANCE <br /> c <br /> DIODE <br /> T PAYLESS FOREIGN CAR RTAR as, cHAN � Svc.PIC PROD Pr. <br /> O 26 N CHEROKEE R <br /> E . LODI CA 9S240 03 NC, NC 251 Oft. <br /> _ LOCATION TAX EXEMPTION NO. <br /> R 7LSSO1 <br /> SERVICE DATE SALES REP N0. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODEHANDUNG ASSOD SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> CODE CODE <br /> n 1 299-334-3112. 05-195-469P I I. 0775 <br /> SERVICE/ �— KL"1 " SALES TOTAL WASTE SOLVENT RUMS CC SERVICE CHANGE uuxG¢ IW PROMO MS <br /> DEPT PRODUCT NUH$E.R. JNII PR ICC OUAN. CHARGE TAX CHARGE MIN. CLEANSPEM TERM SERNME TERM SCHMI LEASE :ti0. GN <br /> cosi SK DOT EKSlrvmal� Irvmvi CODE NO. RE <br /> lotIWO 00015284/SNAP ON 1 7E.95 O.CO 7A. 95 ^u.OP 11 7t4 8 L <br /> 2 E <br /> 3 C <br /> 5 C <br /> 5 C <br /> 6 C <br /> 7 E <br /> B <br /> 9 E0 C <br /> E <br /> 11 E <br /> 12 C <br /> 9 <br /> . 5 0.00 78.95 CHECK GOD POOR O.OG y x0 NO <br /> TOTAL-SERVICE/PRODUCTS 78APPROPRIATE I DEGILS IN PUCE y ❑ MALf PROPERLY GROUNDED /S ❑ <br /> BOXES MACHINEINESS DN ❑ AND LEGIBLE ✓t-- LOCAIPHONENO.SVGKEA A--] El Z <br /> 6 CLEANLINESS BUBBLE LLE /fu7j ❑ <br /> —F INSTALLED ❑ ❑ AFfIXEOTO MACHINE W <br /> USEPA TRANSPORTERS ID NO. USEPA TRANSPORTER 210 NO. t GENERATOR USEPA ID NO. GENERATOR STATE ID NO. LAMP assDnaLY ❑ ❑ EMfRCEmy croslrvc SPENT SOLVENT MEETS ,dr❑ <br /> ILD9P-49gT.`;in2 CAL!'."CIT 7554 UMUIIIDN ov ERENCYUD CLSING ❑ accEPrnxcFcRITERIa �I 2. <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID. Iz coNTANxFns ID. TOTu u.uxrt ]] C I CERTIFY THAT MY TOTAL <br /> NO TTP ANniV YNT L SK DOT NUMBER S 6 J G WABTE STREAMS ARE WITHIN W <br /> ASTF COMaUSTI9LF L[ Q11ID# N.O.$, gPF.TR:TL c UP NAPHTHA ) NA1993 CN /� f 7 4 ONE OF THE FOLLOWING <br /> CATEGORIES. <br /> A. G1110001 OO15YD039,DO4C-)(ERG91?8 )6. 7LOS/CAL OTOY20U35JMOMH p <br /> Z <br /> NITULS Y <br /> B. 120 LBB.T02,200IBS.RAONTH V <br /> Q <br /> C. INITIAIS W <br /> GREATER THAN IRW LBSMANM Q <br /> D. N <br /> NGU B <br /> DESIGNATED FACILITY NAME AND ADDRESS SAFETY—KLEEN SYSTEMS, IN- USA EPA ID NO. CAT0006L 3 968 1z <br /> 5050 SALIDA BLVD SALIDA, CA 95166 S7ATEIONO. CATO O6 3 6A Q <br /> W <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: - ANIFEST O. I AGREE TO PAT THE ABOVE CHARGES AND TO BE BOUND By THE TERMS AND TOTAL CHARGE G G V <br /> CHECK NUMBER ///���/''� CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DMUMEM. (FROM ABOVE) 6 / <br /> L/^ 7� V WYB BER CE BAE lol PLEASE CHARGE MY A NT FOR THIS TRMISACTION UNLESS OTHERWISE <br /> S !Y/ /�• \/1 ❑PREVIOUS BALANCE AS fDU-WS INOICATED IN THE PAYMENT RECEIVED SECION.THE INDINOUAL SIGNING THIS W <br /> MIN. <br /> UDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (WASTE WASTEROM IN. fn <br /> INVOICE IN I AMOUNT$ INVOICE# AMOUNT$ LOR RE Q 7 TMebb L1Ny Pd N•vLv..wiM mm.YvP�a^MMM.wu�.a.m.n.e.b w.w w.,•. <br /> • "°°'m""I°,a.—°"I°°'m°°•�s"°'°°'°'°"®°"'w'"m`w°'•°•°"'°""'°'T'"„°°„"°„' TOTAL DUE <br /> PREVIOUS MANIFESTCODE BED# / <br /> CREDIT DO NOT WRITE IN THE AREA BELOW <br /> ARD NOTr <br /> Pnm CuMOmar me� <br /> AMEX <br /> LLLM VISA f ! iI 40.9764 <br /> Mc �" <br /> CUSTOMER REFER ' Customers' u Urketl Represerllet{q / <br /> INFORMATION is T.� <br />