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2309 West Hammer Lane PR0546737 <br /> September 2, 2021 Program: HW <br /> PHOTO 2: Consolidated manifest missing waste code and destination facility ID number. <br /> RDw L�rx�T7—uPr�:,�rrar.��,ro.,.,. DOC.EXP. mom.. - <br /> Richartlson,TX 75080 vrv✓wsafery-kleen.com ` J FOR SEERVICE CALL BRANCH MANAGER SERwCE WEEK Desu¢ <br /> " CUSTOMER NO. ' /uam6¢A' <br /> C J PUE <br /> COD PREVIOUS BALANCE BAL OVER 60 DAYS AS <br /> J CODE U0�pus <br /> �RSJeyD <br /> 4r3 3 ZA- CUSTOMER SEGMENT CHAIN OUTER SVC.P/C PROD.PIC (III) <br /> �1 L COUN <br /> /7i'/�'17111 In¢Jeytl <br /> Z 7OQI ��7 LOCATION TAX EXEMPTION NUMBER <br /> I'sep <br /> SERVICE DPTpug <br /> �E SALES REP N0. CUSTOMER P.O.NUMBER CUSTOMER PHIONE# TAX CODE DATE EOPT/PROD ORDERED SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> -y to J�1� •1/17-5� eo) <br /> CHLORINE TEST RESULTS SK DOT aERVICE CHANGE cxexse PROMO ISS <br /> SERVICE/ SURVEY SALES TOTAL CC SERVICETERM eCx Deis RELEASE NO. <br /> REPT PRODUCT NUMBER UNIT PRICE QUANTITY CHARGE TAX CHARGE ALO° IW <br /> xP�ex r <br /> CHLOR-DT sites lxmus NUMBER TERM EEKSIOrvmAU NO. <br /> 1 � ❑ 'IFSa) <br /> 2 ❑ I❑ 4{I <br /> 3 1 1❑ I❑ <br /> i 4 ❑ I❑ <br /> 5 ❑ 1❑ <br /> 6 ❑ ❑ <br /> . 7 ❑ I❑ <br /> �B ❑ ❑ <br /> B ❑ ❑ <br /> TOTAL-SERVICE/PRODUCTS TANK • DAT <br /> CAPACITY <br /> •• • • °• = • MANIFEST N0, USEPA TRANSPORTER ID NO. �A X � E <br /> GENERATOR: VEHICLE OTHER I NO PREOUAL REQUIRED,NO HALOGEN TEST PR T AME SIG URE <br /> HAZARDOUS Vr'ASTE FLUIDS NON-VEHICLE 2 NO PRE. <br /> REQUIRED,HALOGEN TEST AT PICK-UP 110 / / - 199 <br /> CLASSIFICATION• ON LV FLUID$ o55(LoT D E 6 <br /> CESQG ❑f ❑3 3 PR <br /> REQUIRED,NO HALOGEN TEST GENERATOR USEPA ID NO. GENERATOR STATE ID NO. Z <br /> 4 PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP <br /> SOG/LQG ❑2 ❑4 •REFER TO REVERSE SIDE FOR DEFINITIONS X i 7� <br /> 11.US DOT DESCRIPTION(INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) PRINT NAME SIGNATURE 3S <br /> t2.CONTAINERS 13. TOTAL 10.UNIT <br /> N0. TYPE QUANTITY WT OL SK DOT NUMBER <br /> A. ��44 � f�vv, x,74--d,/w Z�.. , 7S' rr2:y� �I LU d <br /> B. 2 <br /> Ix.o <br /> C. LL)U,1 J ' <br /> D. <br /> >: <br /> 0 <br /> LLI <br /> FE F CIL— ITy NAM�j ND AD RESS CI Y <br /> dT� p��� U <br /> �_ n _ USA EPFI ID NO. LLI a <br /> CASH ❑ AL RECEIVED j STATE ID NO. 1z•U) <br /> CHECK NUMBER APPLY PAYMENT T0: W <br /> �� CHARGE MY ACCOUNT FOR THIS <br /> ❑TODAYS SERWCE/SALE INDICATED IN THE PAYMENT RECEIVED SECTION TRANSACTION UNLESS OTHERWISE `')Q <br /> ❑PREVIOUS BALANCE AS FOLLOWS �� INDICATED <br /> ED I THE <br /> Vie PAYMENT matCEIV D SE =OTAL DUE < <br /> INVOICE# AMOUNTS ana weel,c,sxa ere x, N olazslBea.aesa;oee <br /> INVOICE# <br /> AMOUNTS us.Enmmx,ne„1xl P,o1�`°m gPo�a�uon ror xexsponalun ecco,Q�,o,Ne epprcatl��a9eo,marl,ea DO NOT WRITE IN THE AREq BELOW <br /> s q exa me u.SD <br /> . ePxrN,pm araxsppxa,o�. re¢waxore a 1rre <br /> ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS <br /> MANIFEST CODE SEO# DOCUM T ARE INCORPORAT D HEREWITH MADE A PART HEREOF. <br /> Print <br /> AMEX EXP,DATE Nam C�v <br /> VISA �I� II�� � 1 <br /> MC -E • X 1 <br /> �i --- .F F •. uENEgATOR/ PP E TED REPRESENTATIVE SIGNATURE <br /> ---__ —SEE REVERSE SIDE FOR IMPORTANT INFORMATION <br /> Lydia Baker, SR. REHS Page 2 of 12 <br />