Laserfiche WebLink
V 5400 Legacy Drive,Cluster II,63 800-669-5740 DUNS NO. 05-397-6551 FED.ID NO. 396090019 <br /> WE CARE. SCHEDULED SCHEDULED <br /> Plana,Texas 75024 www.safety-kleen.com 5 FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SERVICE WEEK TERRITORY <br /> sutBtp•BIew CUSTOMER NO. <br /> C CREDIT CODE PREVIOUS BALANCE BAL OVER 60 A <br /> U <br /> pyyq ,- y --waa• r o t',Si�.�.+y,4 CUSTOME CHAIN OUTER SVC.P/C PROD.P/C <br /> T g:34.8=4 L,r4 ..F:idB'e�P 4.Mr3R Y:pa- SA..e SEGMENT CO NTY <br /> Mi LOCATION TAX EXEMPTION NO. <br /> f. <br /> SERVICE DATE SALES REP N0. I CUSTOMER P.O.NUMBER CUSTOMER PHONE F= TAX CODE DATE EOPT/PROD ORDERED I SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> SERVICE/ REMARKS/ SALES TOTAL WASTE SOLVENT/DRUMS SERVICE CHANGE c u',� INv. PROMO MSOS <br /> DEPT DUAN. CHARGE rccrc CC TERM SERVICE TERM "CH ATE CODE N0. GIVEN <br /> PRODUCT UNIT PRICE TAX CHARGE MIN. LnN a;1 CONT SK DOT <br /> 1 ❑ <br /> 2 ❑ <br /> 3 ❑ <br /> 4 ❑ <br /> 5-- <br /> 6-- <br /> 7 67 ❑ <br /> 8 ❑ <br /> 9 ❑ <br /> 0 ❑ <br /> 1 ❑ <br /> 2 ❑ <br /> CHECK GOOD POOR YES NO YES NO <br /> TOTAL SERVICE/PRODUCTS APPROPRIATE DECALS IN PLACE MACHINE PROPERLY GROUNDED <br /> MACHINE CONDITION ❑ ❑ AND LEGIBLE ❑ ❑ LOCAL PHONE NO.STICKER El ❑ Z <br /> BOXES A CLEANLINESS FUSIBLE LINKW <br /> INSTALLED ❑ ❑ AFFIXED i0 MACHINE El ElUSEPA TRANSPORTER 1 ID NO. ITRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. LAMP ASSEMBLY ❑ ❑ EMERGENCY CLOSINGSPENT SOLVENT MEETS <br /> CONDITION OF LID UNOBSTRUCTED ❑ ❑ ACCEPTANCE CRITERIA ❑ ❑ <br /> /4. I CERTIFY THAT MY TOTAL <br /> UNIT <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) 12.CONTAINERS 13. TOTAL NO TYPE QUANTITY WTSK DOT NUMBER WASTE STREAMS ARE WITHIN W <br /> ONE OF THE FOLLOWING <br /> I.,t <br /> ..� Itikfy{,)a3P $t(1{•'f{f®F :3F•QfiTL!•f`f::_".r'7,Tt T7 ..&Stt`F1:Y�31?SN is :a. i-..; CATEGORIES. <br /> 1 0 TO 220 LBS./MONTH O <br /> Z <br /> INITIALS Y <br /> I. 220 LBS.TO 2,200 LBS./MONTH <br /> INITIALS W <br /> i. <br /> - GREATER THAN 2,200 LBS./MONTH a <br /> n <br /> c <br /> N� <br /> ), INITIALS Q C <br /> DESIGNATED FACILITY NAME AND ADDRESS CERTIFY THAT NO MATERIAL CHANGE HAS OCCURRED USA EPA ID NO. Z a <br /> EITHER IN THE CHARACTERISTICS OF THE WASTE Q <br /> MATERIALS OR IN THE PROCESS GENERATING THE STATE ID NO. W cc <br /> WASTE MATERIALS. cc <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: MANIFEST NO. I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE V rte'. <br /> CHECK NUMBER CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) >H <br /> TODAY'S SERVICE/SALE PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE �'Cc <br /> INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS WASTE MIN. W d <br /> ❑ PREVIOUS BALANCE AS FOLLOWS LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE; N <br /> INVOICE# AMOUNT$ INVOICE# AMOUNT$ •Thla Ie to cen,y that the above-h—W mww,are are Properly classified,peckaped,marked end labeled,ar,d ore h <br /> proper cocdemob,narnponmloa e000mlno to the appllcabloragulauons of the Daparavern of rrarrep—h-• TOTAL DUE <br /> PREVIOUS MANIFEST CODE SEO# <br /> CREDVISA' I.ru I!ul VA11TE IN THE AREA BELOW <br /> CARD No <br /> I I����j Print Customer Name <br /> C`� =1 <br /> ITEXP.D7 i <br /> -17- N �_I—_t MSA i e <br /> EMERGENCY CALL By: <br /> CUSTOMER REFERENCE Customers Authorized Representative <br /> --__r__� <br />