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Cilie i to Waste Management, Inc 35151 Old Skyline Road,Kettle"tan City, CA 93139(559)386-9711 FAX(559)386-6109 Credit Application 'ENERAL INFORMA ON: .m Nemo -7 Li ki t use area code) F X lino u"67—r a ante safe) !'Sa;+ddreea �'` Il n e ty state Zip usin."A City Sure Zip Type o Brtsittess Cwnraetor•s license w - t.esgth of time m meas l:-'-� , Please check one: Sole ner Partnership n rued: Credit limit requested Gov't Agency Cotporatlon fStwa incorporated in: _� Purchase Orde Job w OWNERSHIP: Nam( prtnd =air-peaty Social Semarty Number 11. Phone(include gran code) . Halling City state Zip Name of 'ndpeV We Social Security Number Title Phoma(include area code) Mailing Addrom City State zip Name of print pal/responsib a party Social Semuity Number tie ow(include area code) Mailing Addrmis city scale Zip REFERENCES (Sir month Inntt Firm Name ` r /4 �- Account Number Phone (include area anis) FAX(include as code) 7,4 Halling City sate zip . Finn Name Account Number Phone (include arse e) FAX(include area code) Martinacuity State zip Firm Name VAccount Number Phone (include area code) FAX(include area code) M ting Address City Zip \NK REFERENCES: ndBnwch /_ Account Number Phone (include area anile) FAX(include area cods) :Lf Mailing ty State P NamdBrsn Account Number Phone (include area code) FAX(include area code) Mailing Address City Zip NamdBranch Account Numbs Phone (include area code) FAX(include area code) Ma"igAddreas Uty State p All information in this Credit Application is solely for the purpose of obtaining credit and is warranted to be true. Uwe hereby authorize Chemical Waste Management, Inc to investigate the references listed pertaining to y/our credit and financial rsponsibility. r4intea ruane Signature Title Printed name Signature Title Date Printed name Signature Title Date Secretary's Printed Name Office Manager's Printed Name