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115 JYVV I.Y.1y-v.,V uc , v I—----1-.v <br /> www.safety-kleen.com FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SCHEDULED SCHEDULED <br /> Plano,Texas 75024 W �yti��/J.' SERVICE WEEK TERRITORY <br /> G t STO NO. <br /> 1181p 1681 �,. I <br /> 7 ; CREDIT t SAIL.OVER 60 DAYS <br /> I;tJ.r+( 6 CODE PREVIOUS BALANCE <br /> t,Ac � 6 ah , ,�/" ��f) Y. cuSTMENT CHAIN OUTER SVC PIC PROD PIC <br /> 6�.r i� SEGMENT COUNTY <br /> • LOCATION TAX EXEMPTION NUMBER <br /> SERVICE DATE ISALES REP N0. CUSTOMER P.O.NUMBER I CUSTOMER PHONE# I TAX CODE DATE EQPT/PROD ORDERED SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> SALES TOTAL CHLORINE TEST RESULTS SK DOT SERVICE CHANGE CHANGE PROMO <br /> DEPT SERVICE/ SURVEY NITI RICE G TITY CHARGE nALOGENresTER CHLOR-D-TECT NUMBER CC TERM SERVICE TERM syy%vw'E NO. <br /> RELEASE NO. <br /> PRODUCT NUMBER '��`rr TAX CHARGE PASS FAIL RESULTS(PPM- TESTERS INITIALS (WEEKS)(INITIAL) I <br /> U ❑ ❑ <br /> o W ❑ ❑ <br /> 3 s•. c. ❑ ❑ <br /> ❑ ❑ <br /> fY -i ❑ ❑ <br /> 7 LJ ❑ El <br /> 3 ❑ ❑ <br /> 3 ❑ ❑ <br /> TANK '•- DAT g IZ <br /> TOTAL-SERVICE/PRODUCTS CAPACITY <br /> •- • • :• • MANIFEST NO. USEPA TRANSPORTER ID NO. XGENERATf <br /> WR AM SI.WATURE <br /> GENERATOR: VEHICLE OTHER 1 NO PREQUAL REQUIRED,NO HALOGEN TEST <br /> HAZARDOUS WASTE FLUIDS NON-VEHICLE 2 NO PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP n { �.,�W DA' <br /> CLASSIFICATION* ONLY FLUIDS 3 PREQUAL REQUIRED,NO HALOGEN TEST G N 5ATOR USEPA ID NO. GENERATOR STATE ID NO. <br /> CESQG ❑ 1 ❑3 4 PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP X <br /> SQG/LQG ❑2 ❑ 4 REFER TO REVERSE SIDE FOR DEFINITIONS A° sy3 PRINT NAME SIGNATURE <br /> 1 1.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID. 2 CONTAINERS 13. TOTAL NO. 14.UNIT SK DOT NUMBER \F <br /> TYPE QUANTITY Wi OL <br /> W <br /> A �J/ c ,Ne Recycle. <br /> 0. <br /> f .4/'�6 .r .:a A C` �.,.a 3 t'-- �.*er <br /> ._ <br /> N. <br /> w <br /> aie / LU <br /> VI <br /> '• W' <br /> INTERMEDIATE FACILITY NAME AND ADDRESS USA EPA ID NO. <br /> STATE ID NO. J <br /> Or <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE TOTAL DUE I <br /> CHECK NUMBER INDICATED IN THE PAYMENT RECEIVED SECTION. <br /> ❑TODAY'S SERVICE/SALE Customer certifies that the above-named materials are property classified,described,packaged,marked DO NOT WRITE IN THE AREA BELOW <br /> ❑PREVIOUS BALANCE AS FOLLOWS and labeled,and are in proper condition for transportation according to the applicable regulations of the <br /> U.S.Environmental Protection Agency and the U.S.Department of Transportation. <br /> INVOICE# AMOUNT$ INVOICE# I AMOUNT$ ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS <br /> ID I MARD <br /> OUSMANIFEST CODE SEG!# DOCUMENT ARE INCORPORATED HEREWITH MADE A PART HEREOF. <br /> ( _ viaIT Print r21 r NO Name <br /> CREDIT CARD NO. AMEX EX� <br /> VISA- • X � ..-.f ,,_�'�! t <br /> EMERGENCY CALL GENERATOR/SHIPPER DESIGNATED REPRESENTATIVE SIGNATURE e <br /> CUSTOMER REFERENCE <br /> INFORMATION 1-800-468-1760 SEE REVERSE SIDE FOR IMPORTANT INFORMATION <br />