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1301 Gervais Street-Suite 300 DUNS NO. 053918551 FED.ID NO.398030013 CUSTOMER <br /> Columbia,South Caroline 2$201 FOR SERVICE CALL BRANCH MANAGER DOC.EXP. cCHEDUTEN ICE EOPEo <br /> SahlyElue. CUSTOMER NO. - <br /> ) MGI)Q'r3°71 tD <br /> U () (`} �l •�„ .$y. F r {,dP "L^' CODE I PREVIOUSBALANCE <br /> S _/t <br /> T ":¢+,'(,�r rbf LC-E'�I ''A'F if G,cE( j °U CHAIN OUTER SVC.P/C I PROD.P/C <br /> E • LOCATION TAX EXEMPTION NO. <br /> R b " a"bA4 I Q is I <br /> SERVICE DATE SALES REP NO. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODE NACODE° COD SERVICETAX C.O.M.S.TAX PRODUCTTAX <br /> J FY1 7 '7 -i .Q7 <br /> OEM SERVICE/ SERIAL F ENUM J SALES TOTAL WASTE SOLVENT RUMS SERVICE clwK;e cluxM <br /> INV. PROMO MSO$ <br /> PRODUCT i ff DUAN. CHARGE TAX CHARGE MIN. claw sPYerrt • ' SK DOT CC TERM SERVICE TERM Ns.wTE �E NO. GIVEN <br /> MIME NRVL TNwA» <br /> 1 S'"•Aa !E1t71F 06!L&V Z-. .2H. / � , s� pD ❑ <br /> 3 r'V Zlfyr Z. 0 Z. & El <br /> 5 7s , z '#y 'L' �� J ❑ <br /> B 9i iY" - ❑ <br /> 7 .. d` ❑ <br /> B <br /> B ❑ <br /> 0 <br /> M 2 ` <br /> YES <br /> TOTAL-SERVICE/PRODUCTS APP°NEONROPRNTE am P0°R DEDMS IN PLACE YESN0 MMAINE PRDREMY GROUNDS) x9 <br /> ( .f <br /> MACNINE C3NMiDN MID LEfa11E ❑ ❑ ❑ ❑ <br /> s. r•. . : R.t;, BOXES aGEMAWEse ❑ ❑ L3cuP N3 sncem Z <br /> RISIBELWN M11EITOWCHNE <br /> SP-D NO. US Q TAAfI PQ T iR: J Qfl�USEPA ID N0: GENERATOR STATE ID NQ ~ INSTALM, ❑ ❑ ❑ ❑ W <br /> LAMPASSEMSY SPENt 60LVBR NESTS <br /> CONDI93N ❑ ❑ OPUDU.NCYCLONNG ❑ ❑ OCCEPTM'CECRRERIA ❑ ❑ <br /> • "''` K] �r � ' V bid `�. C ^a •�-:,.. DF UDGNDSSTRUCim <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) 12.w HINT 1P. TOTAL M.UNIT NC Oar rvumeER FY THAT MY T AL G <br /> f l�� r S WASTE STREAMS ME WRHIN W <br /> > y* ONE OF THE F°LLOINND G� <br /> f I rJ cXTECOME& <br /> 3 <br /> (� OTO ESOrH O <br /> D ,2PLESNONTH Q <br /> TML9 <br /> cRurel z.ND L3sawxTx Q <br /> DESIGNATED FACILITY NAME AND ADDRESS A- <br /> aAFL"`TY-FLEE IT SYSTEMS, i13 EITHER THECATEuowxEH^s°OCnRmUSAEPAIDNO. Q <br /> EIRIER IN THE OTHE P OMSSS OF THE WASTE <br /> MATERWS OR IN THE PROCESS GENERATING THESTATE ID NO. I{! <br /> 92 <br /> WASTE MAreaMls. <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENTTO: t'gANIFEST:ND I AGREE TO PAY THE MOVE CHARGES AND TO SE SOUND B1'THE TERMS AND TOTALCHARGE V <br /> CHECK NUMBER l e CONDRIONe SET FORTH ABOVE AND ON THE REVERSE BIDE of THIS DOCUMENT, (FROM ABOVE) 71— <br /> ❑TODAYSSERNCES&E ,.fJfy 6* T �+ a^ PLEASE CHARGE MY ACCOUNT FOR THIS IIWISIGTXJN UM1YESSOTHERWISE �(L <br /> INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDNIDWL S WING THIS WASTE MIN. Q <br /> ❑PREMWSSIWICEAS PoLLOWS UDR MESSAGE DOCUMENT IS OULY AUTHORIZE°TO MN AND SND CUSTOMER TO ITS TERMS. (FROM ABOVE) �a <br /> INVOICE AMOUNTS INVOICE# AMOUNTS •"'NNnanryu,nw°'°^""""°°"'°r'"�°°'°°'^r°.'"'°'P'a'ge."""°°"°u°.'°'"m'^" <br /> - ,w.emu.,, ,.w,.�,el,Nmn,.ww>,n.,.w+l,,,,wm.•c.on..aT,.,.Pum,. TOTAL DUE <br /> PREVIOUS _ . ..... -_-. _.. -...._ MANIFEST CODE SEC Ebk YA, tt,y � �^1 DO NOT WRRE IN THE AREA BELOW <br /> CREDIT � : ••-� ///LLL J '1 <br /> A NC <br /> CREDR CARD NO -EXP. ATE PrWCustom•r Na a 0 <br /> AMEX ,.� �•� , 1/ M0�?}93'71Z8 <br /> VISA a • �i"7,. . O '�i Q <br /> C <br /> CUSTOMER REFERENOE. _ <br /> C oma( MeWa <br /> PUaIzeD epreSara ' <br /> NG(TRAAdTI(1N :r 1 •.'.: p' .1 • ,• �... .. ----- _. <br />