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AW 5400 Legacy Drive, Cluster 11, B3 800-669-5740 ,JZ 1-1-c2�7- DUNS NO. 05-397-6551 , FED. ID NO. 396090019 <br />%dkjo 1 kilvi"JI-1 <br />Plano, Texas 75024 www.safet-kleen.com c -v M7 <br />y <br />FOR'SERVICE CALL <br />BRANCH MANAGER DOC. EXP. <br />SCHEDULED <br />SERVICE WEEK <br />SCHEDULED <br />TEPR,10R, it <br />CUSTOMER NO. <br />RA�Lykffl <br />M010 4 97 44,'50, <br />9-5,1,13-101�� <br />CREDIT PREVIOUS BALANCE <br />CODE BAL. OVER 60 DAYa <br />CUSTOMEFII CHAIN <br />SEGMENT I <br />OUTER <br />COUNT <br />PROD. P/C <br />LOCATION <br />TAX EXEMPTION NO. <br />SERVICE DATE SALES REP NO. CUSTOMER P.O. NUMBER CUSTOMER PHONE# TAX CODE DATE EQPT/PROD ORDERED SERVICE TAX C.O.M.S. TAX PRODUCT TAX <br />DEPT SERVICE/ REMARKS/ SALES TOTAL WASTE SOLVENT/DRUMS SERVICE CHANGE GUNGE INV PROMO MSDS <br />cc <br />DUAN. CHARGE *OF TERM SERVICE SCH.D4T <br />PRODUCT W,, UNIT PRICE TAX CHARGE MIN. CODE NO. GIVEN <br />j CLEAN SPENT CONT. WEEKS INITIAL (Yy WWE <br />S K DOT I <br />El <br />El <br />AA <br />El <br />El <br />❑ <br />El <br />`CHECK GOOD POOR YES NO YES NO <br />TOTAL-SERVICE/PRODUCTS APPROPRIATE PR DECALS IN PLACE❑ ❑MACHINE PROPERLY GROUNDED <br />El MACHINE CONDITION 0 AND LEGIBLE <br />BOXES LOCAL PHONE NO STICKER <br />& CLEANLINESS <br />z <br />FUSIBLE LINK TO MACHINE ❑ <br />USEPATRAN$PbRT, -10 Ndr I USERATRANSPOFITER,�,ID NO�,J, 1GIIENERATOR USEPA IDINO- INSTALLED❑❑ El <br />ERA,, LAMP ASSEMBLY El 11 SPENT SOLVENT MEETS <br />CONDITION EMERGENCY CLOSING <br />OF LID UNOBSTRUCTED ❑ ACCEPTANCE CRITERIA El ❑ <br />11. US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.) <br />12. CONTAINERS <br />13. TOTAL <br />14. UNIT <br />SKDOTNUMBER <br />j <br />k: CERTIFY, THAT MY TOTAL <br />L1j <br />NO. <br />TYPE <br />QUANTITY <br />WT GL <br />--t <br />WASTE ST EAMS ARE WITHIN <br />A <br />ONE OF THE FOLLOWING <br />CATEGORIES. <br />0 <br />0 TO 220 LBS./MONTH• <br />z <br />INITIALS <br />U <br />220 LBS. TO 2,200 LBS./MONTH <br />(j) <br />INITIALS <br />UJ izz, <br />-J!R <br />4 LO <br />GREATER THAN 2,200 LBS./MONTH <br />cn 0. <br />INITIALS <br />> <br />a) <br />DESIGNATED FACILITY NAME AND ADDRESS• <br />I CERTIFY THAT NO MATERIAL CHANGE HAS OCCURRED USA EPA ID <br />NO. <br />z <br />EITHER IN THE CHARACTERISTICS OF THE WASTE <br />(0 <br />MATERIALS OR IN THE PROCESS GENERATING THEI STATE I'D NO. <br />WASTE MATERIALS. <br />I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND <br />LLj �2 <br />CASH <br />TOTAL RECEIVED APPLY PAYMENT <br />ENT TO: <br />TOTAL CHARGE <br />CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. <br />PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br />(FROM ABOVE) <br />> <br />CHECK NUMBER ❑TODAY'S SERVICE/SALE <br />Cc <br />❑PREVIOUS BALANCE AS FOLLOWS <br />INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS <br />AN <br />WASTE MIN. <br />"N' <br />kNOS' <br />LDR MESSAGE <br />DOCUMENTIS DULY AUTHORIZED TO SIGNAND BIND CUSTOMER TO ITS TERMS. <br />VE) <br />(FROM ABOVE) <br />--o-e- <br />INVOICE # AMOUNTS INVOICE # AMOUNT <br />'This is to certify that the above named materials we property classified, foaaaged, marked and labeled, n. — �,� <br />q", r,,V <br />PREVIOUS <br />R IOU <br />EV „ , <br />CREDITO <br />proper condition for transportation according to the appl,cable regulations of the Department of T,anapo,tation,' <br />ii, <br />"A 4 VM4 <br />TOTAL E <br />U <br />DO NOT WRITE IN THE AREA BELOW <br />MANIFEST CODE <br />SEO # <br />int storyler Name p <br />I I W <br />/ , P <br />, <br />CARD <br />ot <br />�, " <br />AMEX <br />"Ik V, -`� <br />, <br />._�! <br />1; 8,1.x. <br />y:E.E. <br />,tistcmei`s At Representative <br />-171-7-7717 <br />CUSTOMER REFERENCE <br />TPI -q 4.PPF=hAr=KIT rr)KITINII IAC r)KI TWIT QL:\/C:DQr Qln[C <br />r <br />INFORMATION <br />I <br />ITT <br />