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2600 North Central Expressway, Suite 400 800 6G9-5740 <br /> "Alef ". / DUNS NO. 05-397-6551 FED. ID NO. 396090019 <br /> Richardson , TX 75080 wwwsafety-kleen .com c FOR SERVICE CALL BRANCH MANAGER DOC. EXP. <br /> 99111q�9I999, CUSTOMER NO, SCHEDULED SCHEDULED <br /> SERVICE WEEK TERRITORY - - <br /> CRID <br /> TT <br /> CODE PREVIOUS BALANCE BA . OVER 6 DAY <br /> ( � t fIt { CUSTOMER <br /> t� � •;7 : I [ 'tg � t _ SEGMENT <br /> OHAIN OR, SVC. P(C PROD. P/C <br /> U0 1 { <br /> LOCATION TAX EXEMPTION N0, <br /> SERVICE DATE SALES REP 111i0. CUSTOMER P.O. NUMBER CUSTOMER PHONE # <br /> TAX CODE DATE EQPT/PROD ORDERED SERVICE TAX C.O.M.S, TAX PRODUCT TAX <br /> . . ,. . . .. . fREMARKS/ <br /> DEPT SERVICE) PRICE CHARGE SALES TOTAL WASTE SOLVE RUMS SERVICE CHANGE CHANGE <br /> TAX CHARGE MIN. n.EAra SPENT 0OF CC TERM SERVICET ERM SLH GATE INv. PROMO MSDS <br /> 1 PRODUCT QUAN. COM. SK DOT WEEK aTIT AL ry v;ra, CODE NO, GIVEN <br /> 2 IN ❑ <br /> 3 <br /> IN <br /> IN <br /> NNe IN IN I _ ❑ <br /> 5 ❑ <br /> 6 ❑ <br /> 7 �� '� ❑ <br /> 8 <br /> 9 ❑ <br /> 0 c f ❑ <br /> 1 ❑ <br /> 2 ❑ <br /> TOTAL-SERVICE/PRODUCTS CHECK GOOD POOR ves NO YES No <br /> " APPROPRIATE DECALS IN PLACE MACHINE PROPERLY GROUNDED ❑ ❑ <br /> BOXES MACHINE CONDITION ❑ ❑ AND LEGIBLE ❑ ❑ <br /> USEPA TRANSPORTER 1 ID N0. USEPA TRANSPORTER 2 1D N0, GENERATOR USEPA ID NO. GENERATOR STATE ID NO. a CLEANLINESS FUSIBLE LINK ❑ ❑ LOCAL PHONE M STICKER <br /> LAMPDITIONASSEMBLY ❑ ❑ <br /> INSTALLED AFFIXED TO MACHINE ❑ ❑ LU <br /> CONDITION EMERGENCY CLOSING ❑ ❑ SPENT SOLVENT MEETS <br /> OF LID UNOBSTRUCTED ACCEPTANCE CRITERIA ❑ ❑ <br /> 11 . US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID) 12, CONTAINERS 13. TOTAL 14. UNIT <br /> NO, TYPE QUANTITY WT OL SK DOT NUMBER I CERTIFY THAT MY TOTAL <br /> WASTE STREAMS ARE WITHIN J <br /> t, ONE OF THE FOLLOWING <br /> CATEGORIES. a^y� <br /> 0 TO 220 LBS./MONTH <br /> I . I z <br /> - INITIALS <br /> 220 LB&'TO 2,200 LBS./MONTH a <br /> INITIALS LLB z:GREATER THAN 2,200 LBS./MONTH J <br /> Cn <br /> DESIGNATED FACILITY NAME AND ADDRESS :::r INITIALS ® u <br /> I CERTIFY THAT NO MATERIAL CHANGE HAS OCCURRED USA EPA ID NO. Z a <br /> EITHER IN THE CHARACTERISTICS OF THE WASTE r <br /> MATERIALS OR IN THE PROCESS GENERATING THE <br /> S CASH ❑ TOTAL RECEIVED =# AMOUNT <br /> TO: WASTE MATERIALS. STATE ID NO. Cr <br /> MANIFEST NO. LLI <br /> I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE U <br /> 19%g <br /> I l t CHECK NUMBER CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. <br /> `� a4 ' _ . , ALE (FROM ABOVE) F, <br /> 1 � PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br /> s isI'D IN ,el BALANCE AS FOLLOWS INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS WASTE MIN. CC a <br /> c ' LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS, L J Q <br /> INVOICE # AMOUNT $ INVOUNT $ y that the above nomad materials are properly clasal(lod, paak.+g©d, marked and labeled, and are In (FROM ABOVE <br /> 'This �a to Cen1r <br /> propor condition for transportaWn accordi�rg to the applkobto rogulneons of tho Department of TmnsporlaJori." TOTAL DUE <br /> PREVIOUS � /1 <br /> CREDIT MANIFEST CODE SEQ # f <br /> CARD NO ~ vrsa y Gc <br /> ' Y �� t DO NOT U El f J I .-i :- AREA 6ELO�ti <br /> f # f �� AMEX EX 0 TE_ RON <br /> Print Customer Name <br /> _ . _ ,a. CA LT ABR NQ <br /> !_! VISA <br /> L <br /> MC i <br /> By: <br />