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3900 Holly Drive PR0535446 <br /> April 2, 2019 <br /> PHOTO 1: Consolidated manifest with incorrect ID number. <br /> ----. +, 1—to NU.386080019 . <br /> CUS R NO. FOR SERVICE CAL4` BRANCH MANAGER CUS <br /> DOC.EXP. SCHEDULED SCHEDULED <br /> / SERVICEWEEK TERRITORY <br /> C.. r 3 Z- b <br /> CODE PREVIOUS BALANCE <br /> BAL.OVER FA DAYS <br /> M <br /> • . '7 CUST <br /> SEGOME CHAIN <br /> 3 7 Z7Q" COLIN SVC.R'C PROD.PC <br /> — ��'��� LOCATION <br /> SERVICE DATE SALES AEP 0. TAX EXEMPTION NUMBER <br /> _ CUSTOMER P.O.NUMBER CUSTOMER PHONE# <br /> TAX CODE DATE EOPT/PRODORDERED <br /> SERVICE TAX <br /> OE?- SERVICE SURVEY' 'VI C .M.S.TAX PRODUCT TAX <br /> PRODUCTNUMBER UNIT PRICE QUANTITY CHARGE SALES TOTAL CHLORINE TEST RESULTS <br /> TAX CHARGE H«—T TLe cHLOR.D-TELT SK DOT CC CHANCE - e <br /> SERVICE PROMO <br /> 1'7Pnss - 1 S1PPM, resrens uxnus NUMBER TERM SERVICE TERM RELEASE NO. <br /> NO <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> 'OTAL-SERVICE'PRODUCTS ❑ ❑ <br /> TANK <br /> CAPACITY <br /> • MANIFEST NO. <br /> iENERATOR: VEHICLE OTHER USEPA TRANSPORTER ID NO. X <br /> aADOUS WASTE FLUIDS NON-VEHICLE NO PR EQUAL REQUIRED,NO HALOGEN TEST o <br /> SSIFICATION- ONLY 2 NO PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP PRINT NAM SIG RE 2 <br /> FLUIDS <br /> CESOG E 0 3 3 PREQUAL REQUIRED,HA HALOGEN TEST GENERATOR USEPA ID N0. GENERATOR STATE ID NO. FACILITY DATE <br /> 4 PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP `• �J Z <br /> DG/LOG 02 ¢ gEFER TO REVERSE SIDE FOR DEFINITIONS T y`J W i` X <br /> a <br /> i DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS.AND ID.) . PRINT NAME SIGNATURE <br /> 12.CONTAINERS 13. TOTAL 14.VNIII T ` <br /> %I "4 NO. TWE QUANTITY VdT VOL <br /> SK DOT NUMBER <br /> *-44 z <br /> >0 <br /> wo <br /> wW <br /> } <br /> 20 <br /> w Z <br /> �Y <br /> j?lATE FACILITY NAME A D ADDRESS_ �. w Q <br /> �' USA EPA ID NO. M N <br /> C''f' STATE ID NO. J W <br /> J <br /> AS f TOTAL RECEIVED APPLY PAYMENT TO: CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWI <br /> cHECKruc�ER O N <br /> O TODAY'S SERVICE/SALE INDICATED IN THE PAYMENT RECEIVED SECTION. <br /> ❑PREVIOUS BALANCE AS FOLLOWS Customer cenitles mat the-Dore-named materels are property';s dad,described.pacwageo,mane - <br /> dna labeled,and are I,proper condition for transponahon a—,ding to the applicable regu:ac:.ns.,the <br /> tMVO1GE# AMOUNT S INVOICE# AMOUNTS U.S.Environmental Frotenon Agency and the U S.Depanmem of Transponatwn. <br /> ADDITIONAL TERMS AND CONDITIONS ON THE REV RSE SIDE OF THIS <br /> MANIFEST CODE SEO# DOCU ARE INCORPORAn�ED HEREW/�rH MAD APART HEREOF. <br /> Pr iQG %l. ( � _ <br /> X . TSE N� .Ili�:a <br /> AMEX <br /> - - VISA rIfF:e • <br /> Lydia Baker, REHS Page 1 of 7 <br />