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One Brinckman Way � ^ <br /> ELGIN,ILLINOIS 60123-7857 (r / PLACEMENT FORM FOR SERVICE CALL BRANCH MANAGER <br /> safegrkleen. 209-545-1011[MONICA SHANNON P96670 <br /> DUNS NO.05106-0408 FED.ID NO.39-6090019 NAME TITLE SIGN <br /> GENERATOR LOCATION BILL TO (IF DIFFERENT FROM LOCATION) 1. <br /> NAME NAME <br /> i 1 <br /> 2 <br /> LNERY ADDRES DELNERY ADDRESS <br /> INFORMATIONiATTENTION UNE INFORMATION ATTENTI N UNE LO SIC CODE Cl <br /> CITY 8 STATE CILIL <br /> TY d STATE BUSINESS CHAIN ASSOCIATION SVC.P/C PROD.P/C <br /> TYPE U <br /> ZIP TAX CODE <br /> ZIP TAX CODE <br /> SALES TAX EXEMPTION NI IMRFR-__ <br /> d <br /> DATE PLACED SALES REP NO. BLANKET ❑rEMPORARv CUSTOMER PHONE NO. HA"DUNG CREDIT SERVICE TAX C.O.M.S.TAX PRODUCT T <br /> CUSTOMER'S CODE CODE <br /> L.'- Iv_f"I P.O.NUMBER p`» - I ,., <br /> SERVICE/ SERIAL SALES TOTAL SOLVENT'DRUMS SERVICE SCHEDULE -P M <br /> DEPT PRODUCT REMARKS/UNIT PRICE QUAN. CHARGE CC DATE CODE EPEE INv. PROMO RELEASE MSDI <br /> NUMBER TAX CHARGE SK DOT TERM YY ww1 :iow 'A'"` o° NO. NO. GIVE^. <br /> I OG'(7GJ a , ;-,Gr7 1 17. o U i7 Z '7 ❑ <br /> 2 I t7�l � �lJ J. v ❑ <br /> 3 <br /> El <br /> 5 ❑ <br /> 6 ❑ <br /> 7 ❑ <br /> TOTAL-SERVICE/PRODUCTS REFUSED SERVICE EXPLAIN <br /> /� .y } (1)NEW APPLK:ATK)N <br /> 2 I Z 7•aC� D� 6.O / PLACEMENT(2}REPLACE DEFECTIVE MACHINE <br /> (3)REPLACE COMPETRNE MACHINE <br /> USEPA TRANSPORTER 1 ID NO. USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. CODES (4)REPLACE HOME MADE VAT. <br /> ILD984908202 ('AL 0000 7 (5)ADDITIONAL MACHINE <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) 12 CONTAINERS 13 TOTAL 14 UNIT SK DOT NUMBER I CERT FY THAT MY TOTAL <br /> NO. TYPE QUANTITY WT.VOL 1 3 S WASTE STREAMS ARE WITHIN <br /> WASTE COMBUSTIBLE LIQUID, N. 0. S. ( PETROLEUM NAPHTHA) NA199 3704 jyj <br /> OOANE OF EGORIESHE FOLLOWING <br /> A. PGIII( DO01 D018, D039, DO40)( ERG#128 )6. 7LBS/GAL D�1 G 0 T 220 LBS/MONTH <br /> W <br /> INITIA S <br /> 3. <br /> 220 LBS.TO 2,200 LESJMONTH <br /> RQ WKS-TE COMBUSTIBLE LIQUID, N. O. S. ( PETROLEUM NAPHTHA) 801 <br /> NA1993 PGIII ( D001, DO18, DO39, DO40 )( ERG128 )( 6. 7#/GL ) f �h ( INITIALS .� <br /> GREATER THAN 2.200 LBS.MONTH <br /> t� <br />�. <br /> INITIALS 6d <br /> DESIGNATED FACILITY NAME AND ADDRESS SAFETY—KLEEN SYSTEMS, INC. ISA EPA ID NO. -r- pU <br /> STATE ID NO. (01,4 , <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 O <br /> CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) Z <br /> CHECK NUMBER ❑TODAYS SERVICE/SALE PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE cc <br /> F- <br /> PREVIOUS BALANCE AS FOLLOWS INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS TOTAL DUE o_ <br /> • LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. <br /> INVOICE# AMOUNT$ INVOICE# AMOUNT$ Irm—ro—'N mai-loos-cm.bd ma—,are P,oeedy c­f­-kg-marked ecd Iao ,-o are <br /> wooer cocdmoc m,o-arsPor. eccwai —wiceole, mac DO INCT WRITE IN AREA BELOW <br /> rg io� agWaWnv of�M Depan r of Trareponalon <br /> PREVIOUS <br /> CREDII MANIFEST CODE SEQ# <br /> - 10 D ^' IV P 9 6 6 7 0 <br /> A 9= Print Customer Name <br /> R DR ARD NO. AMEX EXP.DATE <br /> LE. VISA IN THE EVENT OF _ <br /> L M EMERGENCY CALL I By,)(_ ��- 5688 <br /> CUSTOMER REFERENCE Customer's Authorized Representative - <br /> INFORMATION <br />