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1301 Gervais Street-Suite 300 DUNS NO. 05-397-6551 FED.ID NO. 75-2178928 CUSTOMER <br /> Columbia,South Carolina 29201 WE CAFM, FOR SERkE CALL BRANCH MANAGER DOC.EXP. SCHEDULED SCHED <br /> EDULTERRITORY <br /> MER NO. SERVICE WEEK <br /> CUSTOMER i81CIgiI8t1. � �" <br /> IR <br /> CODE PREVIOUS BALANCE L.44 0 8 <br /> �/J 6 ^ 4 / � BUSINESS CHAIN OUTER SVC.PJC PROD.P/C <br /> C� rt- li s-t ��` (� Q 7YPE COUF ✓ r• LOCATION TAX EXEMPTION NO. <br /> SERVICE DATE SALES REP N0. I CUSTOMER P.O.NUMBER I CUSTOMER PHONE# I TAX CODE ACO�DE SERVIC .O.M.S.TAX PRODUCT TAX <br /> 0 p C S - <br /> SERVICE/ SALES TOTAL WASTE SOLVENT/DRUMS SERVICE CHANGE INV PROMO MSDE <br /> DEPT REMARKS/ pUAN. CHARGE .Ov CC TERM SERVICETERM HDATE CODE NO. <br /> PRODUCT TAX CHARGE MIN.!T- PRIG3 CLEAN SPENT o„T SK DOT EKS INIT m WWI GIVEP <br /> 2 tl6• a.vv r � ❑ <br /> 3 ❑ <br /> 4 ❑ <br /> 5 ❑ <br /> 6 ❑ <br /> 7 ❑ <br /> 8 ❑ <br /> 9 7 ❑ <br /> 10 ❑ <br /> 11 ❑ <br /> 12 El <br /> CHECK GOOD POOR YES NO '� YES NO <br /> El AND <br /> IN P ❑LACE MACHINE PROPERLY GROUNDED <br /> 1:1TOTAL-SERVICE/PRODUCTS APPROPRIATE MACHINE CONDITION AND LEIBLE LOCAL PHONE NO,STICKER Z <br /> ' '✓. ,S O V J �• < BOXES 8 CLEANLINESS FUSIBLE LINK ❑ AFFIXED TO MACHINE ❑ LLI <br /> USEPA TRANSPORTER 1 ID NO. USEPATRANSPORTER 2 fD NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. ~ LAMP ASSEMBLY EMERGENCY <br /> INSTALLED f�� SPENT SOLVENT MEETS 2 <br /> CONDITION ❑ OF LID GUNOBSTRUCTED "�-❑ ACCEPTANCE CRITERIA ❑ <br /> TT r1`9849081)013 72.CONTAINERS 13. TOTAL 14.UNIT I CERTIFY THAT MY TOTAL 0 <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) NO TYPE uANT ry wry L SK DOT NUMBER WASTE STREAMS ARE W THIN W <br /> ONE OF THE FOLLOWING J <br /> WASTE COMBUSTIBLE LIQUID, N. 0. S. ( PETROLEUM NAPHTHA) NA1993 G 704 CATEGORIES.. O <br /> A 220 LBS./MONTH <br /> 40 ) <br /> Gi <br /> GAL <br /> �G�+�wb'Cfl'1oil `�V1RY1`l�l'1!{F•l7+Mtl1f�J�Y1�l'���� - Z <br /> wrrwLs Y <br /> B 220 LBS,TO 2.200 LBS./ML <br /> a <br /> F'mom°^anv$i-•NAP�I 'I N <br /> INITIALS cn <br /> C. GREATER THAN 2,200 LBS,TIONTH IJ^ <br /> (n c <br /> D. INITIALS Q <br /> DESIGNATED FACILITY NAME AND ADDRESS I CERTIFY THAT NO MATERIAL CHANGE HAS OCCURRED USA EPA ID NO. Z <br /> SAFETY-K L E E N SYSTEMS, INC. EITHER IN THE CHARACTERISTICS CHAS <br /> WASTE Q <br /> MATERIALS OR IN THE PROCESS GENERATING THE STATE ID NO. V <br /> WASTE MATERIALS. <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: - MANIFEST NO. ICA GREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE .. <br /> ONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) w�M F <br /> CHECK NUMBER ❑TODAY'S SERVICE/SALE PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE 1J. <br /> INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS WASTE MIN. VJ C <br /> ❑ PREVIOUS BALANCE AS FOLLOWS LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE) (n <br /> INVOICE# AMOUNT$ INVOICE# AMOUNT$ 'ITiB °'pBb1/^°"^'ebo'�'nertie°'""'^e16"•p.openy«e,e.oa�agw.mrxea.na i.ca.a,v,a ar. <br /> wov«mna m o v.eaortam s o m aoa mw,,.�i.00�.of u.o.vl a T,woa.m�.• TOTAL DUEI 7 <br /> PAE\IOUS _- _. ___.-_...'_.___._.._---___.__. ......-----_.-.-__.. __. - .- _.-"_.._ MANIFEST CODE SEO# /, f�� )•�-7 N DO NOT WRITE THE AREA BELO <br /> CAE <br /> CARD NO Print Customer Name Ti G <br /> AMEX M443$8 <br /> VISA <br /> VISA IN THE EVENT OF >� ..t.L�� <br /> i <br /> M By: 005253 <br /> 00525 i <br /> CUSTOMER REFERENCE EMERGENCY CALL Customer's Authonz—eaRepresentative <br /> INFORMATION 1-800-468-1760 THIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br /> I_ <br />