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1301 Gervais Street-Suite 300 DUNS NO. 05.397-8551 FED 10 NO 75-2178928 CUSTOMER <br /> Columbia.South Carolina 29201 WE CARE. SCHEDULED SCHEDULED FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SERVICE WEEK TERRITORY <br /> 53 il® CUSTOMER NO. <br /> CREDIT PREVIOUS BALANCE <br /> 1 CODE BAL. V R 0 DAY <br /> BUSINESS OUTER <br /> f- , :- •,- j�" - r TYPE CHAIN COUNTY SVC.P/C PROD.PIC <br /> !c 5 • LOCATION TAX EXEMPTION NO. <br /> Tr:dr <br /> SERVICE DATE SALES REP N0. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODE HANDLING Assoc.CODE CODE SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> -,Z e— - t: : i,~I _ E Qs Z S r 7 <br /> SERVICE 1 AL t �' SALES TOTAL WASTE SOLVENT/ RUMS SERVICE CHANGE CHANGE INv. PROMO MSDS <br /> DEPT PRODUCT N J M b t P °p f T �'�_ f f- DUAN. CHARGE TAX CHARGE MIN. CLEAN SPENT `O` SK DOT CC TERM SERVICE TERM scN DATE CODE No. H E L E. R S>; N 0. GIVEN <br /> _ CONT Iw EK INITiA i <br /> .�.- 1' Lt- F' /.. T 1. :- . J :'• � ._ � 1t G'.C. C. /� �.. 1 u Lam_ <br /> El <br /> El <br /> El <br /> I ❑ <br /> ❑ <br /> 3 � ❑ <br /> 3 ❑ <br /> ❑ <br /> < • .h t:.7• L ..a :� CHECt. G000 POOR DECALS IN PLACE V�}E-S.� NO MACHINE PROPERLY GROUNDED YES NO <br /> TOTAL-SERVICE/PRODUCTS APPROPRIATE MACHINE CONDITION ❑ AND LEGIBLE 'T" ❑ ❑ ~ <br /> J BOXES &CLEANLINESS FUSIBLE LINK F('��'1'I LOCAL PHONE N0.STICKEP Z <br /> INSTALLED Li--I ❑ AFFIXED TO MACHINE ❑ Lu <br /> USEPA TRANSPORTER 1 ID NO. USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. LAMP AssEMBL EMENSTALLRGENCY CLOSING ❑ SPENT SOLVENT MEETS ❑ <br /> F L r,=k L. y` _ = = q, 3 <br /> CONDITION ❑ OF LID UNOBSTRUCTED ACCEPTANCE CRITERIA R <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS.AND ID.) 12.CONTAINERS 13 TOTAL 14 UNIT SK DOT NUMBER -T is,,_ , I CERTIFY THaT My orAL W <br /> _ _ f NC. 7YPE QUANTITY WT VOLWASTE STREAMS ARE WITHIN <br /> [T 44 L T r " } 1 C • L. V}r (� A+ �- Y L ' �,:W ONE OF THE FOLLOWING <br /> C k rt .. t 4 L •J t l - _ < z 1c *.w:1. _ • .C" , L - -'- CATEGORIES <br /> .�A i 4 - r.V <br /> 0 TO 220 LBS./MONTH O <br /> Z <br /> INITIALS Y <br /> 220 LBS.TO�2, LQS.-MONTH Q <br /> INITIALS W <br /> GREATER THAN 2.200 LBS./MONTH —i <br /> N <br /> INITIALS 137 <br /> DESIGNATED FACILITY NAME AND ADDRESS S k ``'—k? E E a l' ;i?_" 5♦ I*)C CERTIFY THAT NO MATERIAL CHANGE HAS OCCURRED USA EPA ID NO. u.+. G L: .1. Z D', <br /> {r r y r _ EITHER IN THE CHARACTERISTICS OF THE WASTE Q Q <br /> �J.- ✓ L i�V.P: �l `. AL f t.' f MATERIALS 08 IN THE PROCESS GENERATING THE STATE ID NO. +-C i '-'- -1 co <br /> WASTE MATERIALS. W <br /> CA <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 <br /> CHECK NUMBER CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) >F. <br /> PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE CC <br /> ❑TODAY'S SERVICE/SALE CC <br /> INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS WASTE MIN. Q <br /> E]PREVIOUS BALANCE AS FOLLOWS LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE) N d <br /> INVOICE# AMOUNT$ INVOICE# AMOUNT$ �• {- u -r-a to—4 last mve- <br /> e eoo --o Taltt•6 are prop"naasraenpac <br /> . aapac.maraao a,M wbe.' ere rn <br /> anp <br /> props,-w—to,ranapoaaaon-MN to tae appi—ble,eguwi na p,1hc-Dep n—t of Tranapoaaapn• TOTAL DUE <br /> OPREVIOUS MANIFEST CODE SEO# <br /> L[i1 dl� }i J<1 r/%/`� DO NOT WRITE IN THE AREA BELOW <br /> O~ <br /> Print Customer Name <br /> CREDIT CARD NO. AMEX Exp DATE �_/ter OLD • R C <br /> I I VISA - --�`— .!_ `,": ' J 1 14 1' <br /> —'S <br /> By. <br /> EMERGENCY CALL <br /> CUSTOMER REFERENCE Customer's Authorized Representative <br /> INFORMATION I j i i i I ! ! i I I •I I 'I THIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br />