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TRAN'=MISSION VERIFICATION REPORT <br /> TIME 02119/2613 11: 69 <br /> NAME CREATIVEPRINTING <br /> FAX 2094664845 <br /> TEL 2094660288- . <br /> CER.# 00OLONG37152 <br /> DATE,TIME 02119 11:05 <br /> FAX NO./NAME 18665989564 <br /> DURATION 00:02:18 <br /> PAGE(S) 03 <br /> RESULT OK <br /> MODE STANDARD <br /> Sales Representative, <br /> 5 0 L U T 1 0 N S icy �` <br /> ,� <br /> Account t Site Number <br /> Service Address 1...__._l.... 1..._...._I_..._..I <br /> Name Daytin a Phone No, Fax No. <br /> Forsaken Tattoo „y 209-594-7006 ^ ,... <br /> Address [H-mail <br /> 13463 A HWy 8$ fors kentattoo@ymail.com <br /> City/State/Zip Cone Cont+.t <br /> i_ockeford,Ga.95237 P41 <br /> Billing Address(if different that)above) <br /> Name Dayli ie Phone No. Fax No, <br /> Forsaken Tattoo r _ 209-594-7006 _ <br /> Addre;,s Email <br /> 13463 A Hwy 88 µm fors kentattoo@ymail.com <br /> Gly/State/Zip Code Conta A <br /> Lockeford,Ca.95237 <br /> Services to be Provided by Waste Stream Solutiones <br /> Servicer Frequency Additional Pick Up Charge Addhl'-lnal ServiCp6 <br /> 4x Per Year $145.00 if requ(nted by client only Qb nital Waste 0Phatm ❑Chemo Path <br /> MAXimurn#of Waste Containers Mpdical Waste Coniid-ier Size Chat Charge Charge <br /> up to 38 gal sharps and bio Medium NA_ _NA NA <br /> Each Additional Container Charqe Billing Cyclo !,mount Billed Per Cycle Price.. Container Price/Container Price/Container <br /> $35.00 per centsiner if over 38 gni Per Pickup 1$,145.00 NA When requested NA <br /> By signing below I affirm that i am authorized,the Authorized officer m agent of the Customer and have the au iority to bind the Customer to this Agreement.The CuGtomsr <br /> hereby agrees to be bound to the terms and conditions that appear on the second page hereof and comply t+}Ith Waste Stream Solutions Waste Acceptance Polley,both of <br /> what are integral parts of this Agreement - <br /> Contract Effective Date Customer InitialsT <br /> Cus7omer :)ate Name(print) Tltle <br /> Waste Strea .ollftlo s Agent Date Name(print) Title <br /> na118/Zo13 Aldo Gonzale2, lRegionRl Actouftta Manager <br /> Waste Stream solutions reserve the right to deal solely with the customer and not with any third party agent of the customer for all purposes relating to this agreement. <br /> Customer represents and warrants to Waste Stream Soiutlons thal it is the medical waste generator and is cling for on account and not to avoid liquidated damages, <br /> in the amount set forth herin for Customer's breach of representation and warranty. <br />