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2600 North Central Expressway, Suite 400 800-669-5740 <br />Richardson, TX 75080 www.safety-kieen.com <br />S <br />11. CUSTOMER NO. <br />C H 31 21 51 -- <br />Cherokee Freight Lines <br />r <br />1 5463 Cherokee Rd <br />—St 0�!t "^ GST <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />DUNS NO. 05-397-6551 FED. ID NO, 396090019 <br />FOR SERVICE CALL I BRANCH MANAGER I DOC. EXP. <br />CH32532__ 7 4 <br />Cherokee Freight Line <br />• 5463 Cherokee Rd <br />r 1 ' <br />E Fn <br />�LIr1NtC u TAY cnnF HATPT/PROD ORDERED <br />REFERI <br />REVIOUS BALANCE BAL. OVER 60 DAYS <br />CHAIN OUTER SVC. PIC PROD. PIC <br />COUNTY <br />TION TAX EXEMPTION NUMBER <br />,X C.O. .S. TAX I PRIODUCT TAX <br />JtHVIIJt UN1C JMLEJ MEr IVU. <br />9 <br />vv.oivivi�iri ,.,...", .-.-•-.--..._....._.--.. <br />_ <br />_I <br />-lo_ a <br />_ <br />DEPT SERVICE/ SURVEY <br />SALES TOTAL <br />UNIT PRICE QUANTITY CHARGE <br />CHLORINE TEST RESULTS CHANGE CHAN <br />SK DOT SERVICE - MO <br />eeLaceNTESTEn CHLOR.0.TECT NUMBER `C TERM SERVICE seY oN NO. REtTEA6 NO. <br />PRODUCT NUMBER <br />TAX CHARGE <br />PAS FHL RESULTS(i TESTERSINQMALS (W EEKS)jI NITIAL) Z <br />❑ ❑ <br />a <br />❑ ❑ <br />.` <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />' <br />A - <br />DATE �f o / <br />TOTAL-SERVICE/PRODI)q;�7 ^ �. n <br />PACITY <br />GENERAT• - <br />3 <br />• : • • MANIFEST NO. <br />USEPA TRANSPORTER ID NO. <br />X <br />PRIN NAME <br />ATURE <br />GENERATOR: VEHICLE OTHER '?^.F1- NO PREQUAL REQUIRED. NO HALOGEN TEST s <br />NON �I` <br />HAZARDOUS WASTE FLUIDS <br />-VEHICLE 2 NO PREQUAL REQUIRED, HALOGEN TEST AT PICK-UP <br />CLASSIFICATION * ONLY r"�..-U�� 3 PREQUAL REQUIRED, NO HALOGEN TEST GENERATOR USEPA ID NO. GENERATOR STATE ID NO. <br />CESQG ❑ 1 ❑ 3 4 PREQUAL REQUIRED, HALOGEN TEST Ak PICK-UP <br />X <br />SQG/LQG ❑ 2 _❑ 4 REFER TO REVERSE SIDE FOR DEFINITIO)ISr- <br />PRINT NAME <br />SIGNATURE <br />11. US DOT DESCRIPTION (INCLUDING PROP,f_R SHIPPING NAME, HAZARD CLASS, AND ID. <br />z CONTAINERS.TYP <br />NO. <br />TYPE <br />13 TOTAL <br />QUANTITY <br />W UNIT <br />WT OL <br />SK DOT NUMBER <br />`F <br />i <br />W� <br />- �� �t V <br />'CT <br />I <br />S <br />_ <br />v <br />V <br />CC <br />W <br />W� <br />� <br />,_ <br />c <br />OI <br />U <br />W' <br />I TER EDIATE FACILITY PAME AND ADDRESS <br />USA EPA ID N0. <br />cc <br />W , <br />STATE ID NO. <br />- <br />O <br />CASH ❑ <br />TOTAL RECEIVED APPLY PAYMENT TO: <br />CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br />INDICATED IN THE PAYMENT RECEIVED SECTION. <br />Customer certifies that the above-named matenate are properly classfied, described, ackaged, ma[Yed <br />TOTAL DUE <br />/.�� <br />CHECK NUMBER ❑ TODAY$ SERVICE)SALE <br />DO NOT WRITE IN THE AREA BELOW <br />❑ PREVIOUS BALANCE AS FOLLOWS <br />and Iabeled, and are in proper condition for transportation according to the applicable mgula4ns pf that <br />P=. <br />_. <br />• <br />U.S. Environmental Protection Agency and the U.S. Depertmern of Transportation. <br />INVOICE# AMOUNT$ INVOICE # AMOUNTS <br />ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS <br />DOCCAUMENNT�AReNCORPPORATEDHEREWITH MADE <br />IAlPART HEREOF. <br />v <br />��� <br />PREVIOUS <br />MANIFEST CODE <br />SEQ # <br />CREDIT <br />NaPriry [X - t'1 1 t 1� `�- Ci <br />of <br />CARD NO <br />AMEX DATE <br />VISA <br />• <br />�ESENT <br />MIDEMERGENCY <br />CALLGENE <br />OH/IPP DESIGNAGNATURE <br />CUSTOMER REFERENCE <br />�� �� � l l <br />.. <br />