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777 Big Timber Road 11"111 „ uvrT <br /> Elgin, Illinois 60123 D-U-NS 05106.0408 FED. ID NO. 39-60910119 <br /> MANUAL ORDER FORM <br /> . safelq�eleen, <br /> MANIFEST NUMBER '/,fT M 70731 <br /> e <br /> U C STOMER NWMBER — — <br /> S t _ CUSTOMER NUMBER <br /> 0 . M i/ (�%�( / 5 <br /> M 9ME/ <br /> E • "`ii <br /> R A9DRESS / ,/ <br /> —��l���i/l��f'/i ��/7 - � /�� • ADDRESS <br /> CIN/STA II`E ZIP CIN/STATE <br /> ZIP <br /> BERYICE DATE SALEBMAN'8 NO. 9PFCNLIBT CUSTOMER P.O.NUMBER <br /> SHIES TAX EXEMPTION NO. SERV.TAX% C.O.M.B.To PRW.TAX% 9VC-P5 Pfl00.P/5 <br /> • USED MANUAL ORDER BECAUSE: <br /> MACHINE SERVICE SALES TOTAL SERVICE CHANGE <br /> NUMBED CHARGE TAX CHARGE TERM SERVICE TO SCHEDU�LEEATE REMARKS <br /> (WEEKS) E] PREPRINT MISPLACED <br /> EEKB� rINITIAL Iry Wµq <br /> ( PRE-PRINT NOT <br /> ❑ RECEIVED <br /> CUSTOMER REOUESTED <br /> _ EARLY SERVICE <br /> ❑ SCHEDULING <br /> REALIGNMENT <br /> ❑ CUSTOMER <br /> NEEDED PRODUCT <br /> OTHER-EXPLAIN <br /> TOTAL GENERATOR US EPA ID NO. GENERATOR STATE ID NO. -SPENT SOLVENT MEETS YES NO <br /> SERVICE SECTION - ,9� ACCEPTANCE CRITERIA <br /> CONTAINERS "rm.xro<m,Nmxm••.x..•,,,a mxxx,x.wwmyawMo.e•m,l,eo.exvee•i.mxmxa w <br /> <oz,em ae nengonmenam<Nmgmine woau•i.,.s„uamaar m.o,wn..a Nna vemem.' 10M°' 'r•m°'0p°' I certify MS my ImBI waste streams are-mm ane IN IN,fbllOMrN eats nea: <br /> WQuantity <br /> 16 LBS.pq pAL US GOT DESCRIPTION USEPATRANSPORTER <br /> (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS.ANO ID.) ID#ILD051060408 0 tO 220 LBS.IMONTH <br /> the s <br /> 0r� � . fats <br /> 1e2, D rtl L , 809 220 LBS.to 2,200 LBS./MONTH /'L' <br /> NOZIM <br /> . Initials. 4 <br /> d om d L,r of Drums x Ave. Wt/Drum of: Pails) , TANKS , 16 Gal. - , 30 Gal. <br /> DESIGNATED FACILITY NAME AND ADDRESS: <br /> 7-11-1KZ1Fz t/L/eUSA EPA ID No. / Q <br /> / `/. iSTATE ID No. <br /> • • • <br /> PRODUCT NUMBER DESCRIPTION MSDS DEALER , UNIT OF QUANTITY <br /> GIVEN PRICE MEASURE DEUVERED SALES AMOUNT TAX LINE TOTAL <br /> /G'>� Ji+s ! a r ❑ Z30,00 eu A2 Lf6o, ark �- 6�G�? <br /> Z1/Z t U A ❑ D,oJ Qu ;7- Wo.00 gcw,L <br /> 300 1/=,/-' P,46e 511,', ❑ 205, O6 PG �ZU, GrJ 2 5 �0'3,SS <br /> PAYMENT RECEIVED TOTAL PRODUCT <br /> SECTIONEl <br /> AMOUNTS <br /> CASH❑.LTOTAL-RECEIVED APPLY PAYMENT TO: <br /> CHECK NUMBER ❑TODAYS SERVICEISALE TOTAL SERVICE AMOUNT (FROM ABOVE) <br /> ❑PREVIOUS BALANCE AS.PoLLOWS CHARGE MY ACCOUNT FOR THIS TRANSACTION <br /> UNLESS OTHERWISE INDICATED fN THE PAYMENT TOTAL DUE' <br /> INV. # AMOUNT$ RECEIVED SECTION. ALSO HAVE NOTED THE <br /> PRESENCE OF MACHINE, SOLVENT, AND <br /> INV. III <br /> AMOUNT$ REVERSE SIDE.AGREEMENT INFORMATION ON THE <br /> INV.# AMOUNT$ INVOICES ARE SUBJECT TO AN INTEREST CHARGE OF THE LESSER OF 14496 PER MONTH(18%PER ANNUM) <br /> OR THE MAXIMUM RATE ALLOWED BY LAW ON ANY UNPAID INVOICES THAT ARE NOT PAID WrrHIN 30 DAYS. <br /> • _ IN THE EVENT OF DEFAULT,SAFETY-KLEEN SHALL BE ENTITLED TO RECOVER <br /> C S OF COLLECTION INCLUDING SONABLE A S FEES. <br /> 1: ::: • ..I • .. <br /> PRINT <br /> PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION .ziX oAa� GNAT R PRE ENTATIVE SIGNATU NAME <br /> /'� PARRTVVNO.1322(REV.11/92) <br />