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Columbia, South Carolina 29201 FOR SERVICE CALL BRANCH MANAGER SCHEDLED SCHEDULED DOC. EXP. SERVICE SERVICE WEEK TERRITORY Itl81®. CUSTOMER NO. i � NO YES NO r + C' � F.,i i� F_..o. `" 1 7 � > L'f GROUNDED 11- E]MACHL LJ CREDIT PREVIOUS BALANCE CODE BOL. OVER 60 DAYS U BOXES I S � E] AFFIXED AFFIXED TO MACHINE ❑ LU BUSINESS CHAIN SVC. P/C I PROD. P/C T V INSTALLED LAMP ASSEMBLY ❑ ❑ EMERGENCY CLOSING SPENT SOLVENT MEETS TYPECOUNTY O CONDITION OF LID UNOBSTRUCTED Ei Ej ACCEPTANCE CRITERIA 1 M • LOCATION TAX EXEMPTION NO. E 11. US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.) R DATE SALES REP N0. CUSTOMER P.O. NUMBER CUSTOMER PHONE # G TAX CODE �coDSSO C. ACODE SERVICE TAX C.O.M.S. TAX PRODUCT TAX rElVICE ';' §g E r .5 ,r1 `!_-� 1 1: .✓A../. �. +.1} .. f,gt i SERVICE/ �DEPTI PRODUCT REMARKS/ UNIT PRICE OUAN. CHARGE SALES TOTAL WASTE TAX CHARGE MIN. SOLVENT/DRUMS CLEAN SPEhT Cnh°: SK DOT SERVICE CHANGE cnANce CC McRVICETFAM sc,to INv. PROMO PERM "IMI CODE NO. .,,� JSDS. GIVENI 1 2 F < 4 5 6H I 7 Si [ rt 1171 12 --�� i ❑ CHECK GOOD POOR YES NO YES NO CALS INTOTAL-SERVICE/PRODUCTS APPROPRIATE MACHINE CONDITION ❑ ❑ SAND LEGIBLE PLACE ❑ L'f GROUNDED 11- E]MACHL LJ il- -. .:.__.,. �. BOXES OCA PHONE NEO & CLEANLINESS FUSIBLE LINK '-# ❑ � E] AFFIXED AFFIXED TO MACHINE ❑ LU USEPA TRANSPORTER 1 ID NO. USEPA. TRANSPORTER 2 ID NO. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. INSTALLED LAMP ASSEMBLY ❑ ❑ EMERGENCY CLOSING SPENT SOLVENT MEETS CONDITION OF LID UNOBSTRUCTED Ei Ej ACCEPTANCE CRITERIA 1 e 11. US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.) 12. CONTAINERS N 13. TOTAL A 14. UNIT v� DL SK DOT NUMBER ';' §g I CERTIFY THAT MY TOTAL WASTE STREAMS ARE 'MTI -IN r .5 ,r1 `!_-� 1 1: .✓A../. �. +.1} .. f,gt ONE OF THE FOLLOWING CATEGORIES. k .,,� f p, Y3,) �,,,. I ✓ ....t 0T0220: - It r: INVLS z j, 220 LEIS. TO 2.200 LEIS./W INITIALS _ `� • GREATER THAN 2,200 LBSJMONTH ...I �• INITIALS Q O DESIGNATED FACILITY NAME AND ADDRESS 1 CERTIFY THAT No MATERIAL CHANGE HAB OCCURRED USA EPA ID NO. EITHER IN THE CHARACTERISTICS OF THE WASTE - -'-�' 5"' Q 1 ,�- . f •'; JJ '% - jy; r ' MATERIALS OR IN THE PROCESS GENERATING THE STATE ID NO. ' t r,; .r W O G �„ - r -".i/• f� ,,,.;sX,...1 WASTE MATERIALS. ,^: - -- ,'-, M 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 CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) > F - CHECK NUMBER ❑TODAY'S SERVICE/SALE --' a PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE IC CC ❑ PREVIOUS BALANCE AS FOLLOWS INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. WASTE MIN. ED a LDR MESSAGE DOCUMENT IS DULY (FROM ABOVE) I L INVOICE # - AMOUNT $ INVOICE # I AMOUNT $ ThL4 L5 tb ce,* at the above-named matedais .e propery cW aiw. packaged, marked ad labeled, end are k, prop. aaMdbn 1. Vansporhllon acca-ding to me appllraNe regplaao,u a/Ne Depanmenl of Transpodalinn.' TOTAL DUE PRE/ILIUS I I MANIFEST CODE SEQ # DIT-,l.._D DO NOT WRITE IN THE AREA BELOW NU i —� Print Customer Name rd CREDIT CARD NO. AMEX EXP DATE VISA r�IN THE EVENT OF I _ T MC L_LL_U CALL _ BY s (CU$TOMERRErERENCE T . i.1-800-468-1760 EMERGENCY -Custom&,-s Aulhorizeid epresentaWe INFORMATION THIS AGRFFMFNT Tt II.:Ti�i( EFS CIN THF RFvizRc P � -