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1301 Gervais Street-Suite 300 h-� DUNS NO.05-397-6551 FED-ID.NO.396090019 CUSTOMER Columbia,° SCHEDULED 7BALANCE ,x{h Carolina 29201 `�" FOR SERVICE CALL BRANCH MANAGER DOC.EXP. �^fGS-00MER NO. SERVICE WEEK : . .. - 272435 C Q [1 J®Lj 4 �j ? r� i cooE PREVIOOVER DAYS C , , r C 8954. 12 STBUTINESSCHAIP/Qw PROD.P/C Q 10998 S HARLAN RD � 2 0791 No 00 ti 0031 E . FRENCH CAMP C A 95231-960C ' LOCATION TAX EXEMPTION NO. R ? ns SERVICE DATE I SALES REP.N0. CUT E NUMBER CUSTOMER PHONE# TAX CODE HANDLING assoc. SERVICE TAX C.O.M.S.TAX PRODUCT TAX CODE CODE V"_j.1 t 20`1-`in3•-6970 0'--' "5a31r':3 Tii 0??L� 1�7?5 7?5 SLKI AL SOLVENT/DRUMS CHANGE CHANGE D EPT SERVICE) REMARKS/ QUAN. CHARGE SALES TOTAL WASTE CC SERVICE SERVICE TERM SCH BATE INv. PROMO MSDS PRODUCT NUMBER UNIT PRICE TAX CHARGE MIN. CLEAN SPENT �, SK DOT TERM (WEEKSHIN171AL) mWM coDE NO, GIVEN 100 3230 1 XX XX 0 ❑ 20 70705 07061937 1 2152ItQQ 19e S-11 ?71. 53 j. 00XX XX 1 111,58 8 _ ❑ 3111-"'778 0 102, 00001 1165 A — _-- ❑ 40 J0001 219000 xx Xx 0 ASK ME ABOUT: ❑ 5 Mail-Back Sharps! ❑ 6 Mail-Back Mercury! 7 ❑ a More Information? Yes/No ❑ 9 Call your local Safety-Kieen Office �] 10 ❑ ti ❑ 12 El NOr 252.0 3 19, S a 271053 0 r Q� CHECK G000 POOR DECALS IN PLACE YES LiMACHINE PROPERLY GROUNDED YES N❑0 TOTAL-SERVICE/PRODUCTS I APPROPRIATE MACHINE CONDITION ❑ ANO LEGIBLE Z BOXES 8 CLEANLINESS FUSIBLE LINK ❑ LOCAL PHONE NO STICKER ❑ W USEPA TRANSPORTER 1 ID NO. USEPA TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. NsrqusD AFFIXED TO MACHINE CC LAMP ASSEMBLY ❑ G �-1 '7 t CONDITION EMERGENCY CLOSING ❑ SPENT SOLVENT MEETS ❑ C R Irl f T 0 0 ry C 1 i t3 CAL 3 0 0 16 3 1 L7 OF LID UNOBSTRUCTED ACCEPTANCE CRITERIA C/ I\LJ iJ lJ LJ !J 11 J LJ 12.CONTAINERS 13. TOTAL 14.UNIT SK DOT NUMBER E I CERTIFY THAT MY TOTAL W 11 .US DOLT DESCRIPTION ' ((IINCLUDINGA PROPER �SHIPPING NAME,HAZARD CLASS,AND nID.) 77 C� �!7 NO TYPE QUANTITY Wr/VOL J L 6�J 5 5 WgSTE STREAMS ARE WITHIN RQ WAS SFA N 7 RE IT kD MA 1 E NL 3 L N1C2,6- P_(xZI l�3.L-Cf 3) LLC�S J ONE OF THE FOLLOWING J �T. �.. � CA7E S. 3' A. ( D0i7]�Df)2t , Sf1>C139, r'�4Ci) (r fiG 1`'A)? 2'/GAL �'"f eTQ 2MNTH p i►' TE PAINT RELATED MA ,.IAL 3 U 3 PGII (ERG 128) D 36 P 11,658 Z !7 r7 1 220 LBS-TO 7,200 LBS./MONTH V I3. ( L105 f=0i33 DOG1 D01fl DL,35 D 39 D04u)? 2 /GA � Q —_Nm — W G' GREATER THAN 2.200 LBSIMONTH J^ I INITIALS Cn D 0, DESIGNATED FACILITY NAME AND ADDRESS s A F C T Y-K L E E N SYSTEMS, INC. EITHER N THEAT CHARACTETERIALRISTICS CHANCE F THE URRED USA EPA ID NO. C A 0 0 ri 0 0 8 4 5.L? Z o EITHER IN THE CHARACTERISTICS OF THE WASTE Q tt-T S S i, T p r q ,rt i F, MATERIAL OR IN THE PROCESS GENERATING THE STATE I D NO. 7 Lt%.�L!+i b4 5 1,7 W" 1l tl T�!t _� i t�E I:_ t' r��.. .H! I~1 V `rl y 5 t3 t't� WASTE MATERIALS. �•n L� U c CASH. ❑ TOTAL RECEIVED APPLY PAYMENT TO: MANIFEST NO. I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE T CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) >H CHECK NUMBERTODAYS SERVICFJSALE PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE C D PREVIOUS BALANCE AS FOLLOWS INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS WASTE MIN. N U e LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE) 'TNR R to wr*Mal Mm Me abo—taed mater"are Properly classmed.packaged,mail-I arM labeled,acid are e, a INVOICE X AMOUNT$ INVOICE p AMOUNT$ ` iJ`E 1 �) Proper wnatw ler tot-portabw a,a i,ng to e,e app�ble regulat,00s of mo Depana of rraasponabon• TOTAL DUE vvim. 1 PREVIOUS _- MANIFEST CODE SEQ Y �f DO NOT WRITE IN THE AREA BELOW CREDIT IC CARO NO ~ A 7 Print Customer Name COEDIT CARD NO. AMEX EXP.DAT ' 21, . )22. r - ' 5 A IN THE EVENT •F AN )4f," MCISq� � y MLiII _r hIV1tHLitNL;Y CALL w Customer's Authorized Representative ,CILWOMME REFE -800-468-1760 RENCE THIS AGREEMENT CONTINUES ON THE REVERSE SIDE