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Piano,TexasfbUL4 -y — <br /> 181Y1q•NIIYA. <br /> DUNS NO.05-397-6651 FED.1p NO,396090018 NAME TITLE SIGN <br /> GENERATOR LOCATION BILL TO (IF DIFFERENT FROM LOCATION) 1. <br /> t2. <br /> r ' L GA�19ry IT <br /> N <br /> SIC CODE <br /> a <br /> iusrOMEC.PIC PROD.PIC <br /> SEGMENT CHAIN ASSO(JIATI SV <br /> N NUMBER <br /> tTMSALES TAX EXEMPTION <br /> SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> DA JE P CED SALES REP NO. CI BLANKET O7EMPORARY CUSTOMER PHONE NO. PATE EQPTIPROD ORDERED <br /> CVSTOMER'S `i^sy{' I �r",�l <br /> I P.O.NUMBER �:• .. {�-�✓` i ..r <br /> ;� •.' ELEASE Msc <br /> SALES TOTAL SOLVENTIDRUMS <br /> SERVICE scHE LE FFK INV. PROMO GIVE <br /> ERVICEI SERIAL REMARKSIUNIT PRICE QuAN, CHARGE TERM f eaa CO° NO. NO. <br /> RODUCT NUMBER TAX CHARGE CLEAN SPENT SK C <br /> t i <br /> 2 <br /> g E <br /> 4 E <br /> 5 E <br /> 6 <br /> 7 REFUSED.SERVICE EXPLAIN �y (1)NEWAPPLICAMON <br /> TOTAL-SEF;VICElPR©DUCTS <br /> DEFECIRVE MACHINE <br /> A () <br /> � TkNcHN <br /> CppES <br /> (4)REPLACE HOVE tMt)E VAT. <br /> U PgiRAAISPORf1=R11CJiVU: USEPATRANSpORTI=R2IDN0. GENERATORUSEPAI©,hi0,;; GENI=RATORSTATE ID,NO. (s) T � <br /> �, S.1 r%AS E7 STREAAMS ARE WITTHIN <br /> i2.GO AINERB 13 TOTAL 14 UNIT SK DOT NUMBER -}><ti <br /> 11,US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD dA-S.AND ID.) NO. TYP UANTITY wTA oL ONE OF THE FOLLOWING <br /> CATEGORIES. <br /> •� _ w" f t... F?"7 5rr' +L µ'1 ,F. .-r�•.f�q+ i '.iir S„�"l 1 1 S`j: '._,i.,r -,. ,'"� ! f+ ,i7 r• I 0 TO 22Q LBs.RAONTH <br /> A. I '! r p t Ll f}5 I7 t { <br /> INITIALS <br /> 220 LBS.TO 1.1—LBS,IMONTH <br /> it <br /> B. N <br /> aiE1 RTHAN2.200LBSIMONTH <br /> C. <br /> INITIALS <br /> D. <br /> 1 b SIGNATED FACILITY NAME AND AIS REBS A �t <br /> r �; ? El•i s`: 't 11S .." . �?". USA EPA ID N© <br /> T, Y ,•,^ a -' t. n I. Ta t 'y ` STATE ID NO. <br /> MENT TO: MANIFEST NO. I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE <br /> CASH El TOTAL RECEIVED APPLY PAY - CONDITIONS SET FORTH ABOVE AND ON THE REVERSF SIDE Op._THIS DOCUMENT. (FROM ABOVE) - <br /> t' '�°"•-� '� LEASE CHARGE MY ACCOUNT FOR THIS TRANSACTIQN-UNLESS OTHERWISE f.^1 <br /> CHECK NUMBER ❑TOOAVS SERVICEISALE - •"- � - NDICATEDN THE PAYMENT RECEIVED SECTION,Y11�F'1NOIV10UAL SIGNING THIS TOTAL DUE <br /> ❑PREAOl1S BALANCE AS FOLLOWS LDR MESSAGE DOCUMENTIS DULY AUTHORIZED TO SIGN AND BINI,)ZUSTOMER TO ITS TERMS. <br /> }} -Thb Is ro ee ty met the 81--ae—metatfela am PeVeryc'W#ad,WM9ed,„ea1ad enalaWee.arm are ie DO NOT WRITE iN AREA BELOW <br /> ' INV04CE# AMOUNT$ I INVOICE# <br /> AMOUNT$ >'�. 'v1 Yvp r prowrrondtla+ra var,.Mtfoe ,m earaana to ral�NaregobVenaol the Depadeentdrreasportaran• <br /> PREVIOUS _ _.___ _ _-_- _ MANIFEST CODE SEQ# +' - 00 1 <br /> CRE61T _ t Print Customer Name <br /> I � <br /> AMEX 'k 4�,•0- 6 <br /> VISA ' OF <br /> =. <br /> MC B <br /> Y Customer's AUthanzed Representative <br /> C 8130-468-1760 THIS AGREE�1i ENT CONTINUES ON THE REVERSE SIDE <br />