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CSG SK -SSL -BOX -21 Brandon S Gaither 01/15/16 09:33 PAGE 1 <br />Safety-Kleen Systems, Inc. <br />2600 N Central Expy, Suite 200 <br />Richardson, TX 75080 <br />CORPORATE: 800-669-5740 <br />24 HR EMERGENCY: 800-468-1760 (Safety-Kleen) <br />2095451011 <br />REFERENCE NBR. <br />CUSTOMER# KI18372 Kia Country 69002951 <br />1515 N Main St SRVC WEEK: 2016-3 <br />Manteca CA 95336-3243 SRVC DATE: 01/15/16 09:30 <br />PHONE 999-999-9999 <br />BILL TO <br />CUSTOMER# BILL TO ADDRESS: <br />KI18372 <br />Kia Country <br />1515 N Main St <br />Manteca CA 95336-3243 <br />PHONE 999-999-9999 <br />PURCHASE <br />ORDER# 77192 <br />TAX <br />EXEMPT# <br />PRODUCT/SERVICES <br />SERVICE/ <br />TOTAL <br />PRODUCT QTY UNIT <br />PRICE TAX CHARGE <br />B3383 <br />DRUM,55 WASTE O.F. 2.000 <br />0.0000 <br />0.00 <br />0.00 <br />SERVICE TERM 24 WEEK <br />90837 <br />MODEL 90 W/2387 5 6365 1.000 <br />109.9900 <br />9.35 <br />119.34 <br />SIN 13130180 TAG 00001170SK13130188 CLEAN 3.00 SPENT <br />0.000 <br />SERVICE TERM 12 WEEK SCANNED YES <br />3383 <br />DRUM,55 GAL FOR O.F. 2.000 <br />0.0000 <br />0.00 <br />0.00 <br />SERVICE TERM 24 WEEK <br />100001 <br />FEE, FUEL SURCHARGE 1.000 <br />9.8600 <br />0.84 <br />10.70 <br />3230 <br />TAX HANDLING RIC DRUM DROP 30 2.000 <br />0.0000 <br />0.00 <br />0.00 <br />------------- <br />TOTAL SERVICE/PRODUCTS <br />____________________________ <br />119.6500 <br />10.19 <br />130.04 <br />TOTAL CHARGE <br />130.04 <br />CREDITS <br />0.00 <br />TOTAL DUE <br />_______________ <br />130.04 <br />UNPAID BALANCE THIS RECEIPT 130.04 <br />Machine clean and good condition? Yes <br />Lamp Assembly Condition Yes <br />Decals in place and legible? Yes <br />Fusible link installed? Yes <br />Emergency closing of lid unobstructed? Yes <br />Machine properly grounded? Yes <br />Local Phone No. Sticker Affixed to Machine Yes <br />Spent solvent meets acceptance criteria? Yes <br />GENERATOR STATUS <br />0-220 lbs/month <br />Customer certifies that (i) the above-named materials are properly <br />classified, packaged, marked and labeled, and are in proper condition <br />for transportation according to the applicable regulations of the <br />Department of Transportation and (Si) no material change has occurred <br />either in the characteristics of the waste/material or in the process <br />generating the waste/material. Customer agrees to pay the above <br />charges and to be bound by the terms and conditions (1) set forth in <br />(a) the General Terms and Conditions provided separately to Customer <br />or (b) any SK agreement signed by Customer and SK, and (2) <br />incorporated herein by reference. Unless otherwise indicated in the <br />payment received section, SK is authorized to charge Customer's <br />