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y. y <br /> Plano,Texas 75024 www.safety-kleen.com v 7- FOR SERVICE CALL v BRANCH MANAGER DOC.EXP. SCHEDULED SCHEDULED T 'T <br /> 5111�•I�Q9 CUSTOMER-NO, w�" SERVICE WEEK TERRITORY <br /> r r <br /> C ,.f.... <br /> CREDIT1-7 <br /> t-r• �3 .tea-`, �y i.'; <br /> lCODE PREVIOUS BALANCE NCE OVER 60 DAYS <br /> ' °�"/ CUSTOMER CHAIN OUTER SVC.PIC PROD.PIC <br /> i�,J d �J'� !Y'�r�Yl �' - SEGMENT COUNTY <br /> 3 9J" ill a, 1 •+ •,}- -`a 3 0 ter +.. <br /> • �`��•�� � � LOCATION TAX EXEMPTION NUMBER <br /> SERVICE DATE SALES REP NO. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODE DATE EQPT/PROD ORDERED SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> SERVICE/ SURVEY SALES TOTAL CHLORINE TEST RESULTS SK DoT SERVICE CHANGE CHANGE PROMO <br /> DEPT UNIT PRICE QUANTITY CHARGE HALOGEN TESTER CHLOR-D-TELT CC SERVICE TERM SCH DATE RELEASE NO. <br /> PRODUCT NUMBER TAX CHARGE PASS FAIL RESULTS PP TESTERS INITIALS NUMBER TERM NO. <br /> I` l 1 _/ ❑ ❑ s I <br /> 2 ❑ 10 <br /> 3 ❑ ❑ <br /> 3 ❑ ❑ <br /> i ❑ ❑ <br /> i ❑ ❑ <br /> ❑ ❑ <br /> 3 ❑ ❑ <br /> 3 ❑ ❑ <br /> TANK ••• - DATE / .;"/ l <br /> TOTAL-SERVICE/PRODUCTS CAPACITY <br /> • r •• • • :• • MANIFEST NO. USEPA TRANSPORTER ID NO. X <br /> S <br /> GENERATOR: VEHICLE OTHER 1 NO PREQUAL REQUIRED,NO HALOGEN TEST PRINT NAME SIGNATURE <br /> HAZARDOUS WASTE FLUIDS NON-VEHICLE P:L„+f T q f•, t L DATE / / C <br /> CLASSIFICATION* ONLY FLUIDS 2 NO PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP _ <br /> CESQG El ❑3 3 PREQUAL REQUIRED,NO HALOGEN TEST GENERATOR USEPA ID NO. GENERATOR STATE ID NO. <br /> 4 PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP X `D <br /> SQG/LQG ❑ 2 ❑4 -REFER TO REVERSE SIDE FOR DEFINITIONS ( "k..• 7 7j c�`IS. PRINT NAME SIGNATURE <br /> CONTAINERS 13. TOTAL 14.UNIT <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) 12. TYPE QUANTITY WT SK DOT NUMBER <br /> W Z <br /> LL <br /> Ls <br /> 1LL <br /> �3 <br /> m LU <br /> G <br /> INTERMEDIATE FACILITY NAME AND ADDRESS USA EPA ID NO. LU W U, <br /> 4 _ <br /> STATE ID N0. I - LL <br /> CASH ❑ TOTAL RECEIVED APPLY PAYMENT TO: CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE TOTAL DUE 1`,ssem a <br /> CHECK NUMBER ❑TODAYS SERVICElSALE INDICATED IN THE PAYMENT RECEIVED SECTION. r _ <br /> �_. <br /> Customer certifies that the above-named marshals are properly classdied,desnlbed,packaged,marked <br /> ❑PREVIOUS BALANCE AS FOLLOWS and labeled,and we 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. LA <br /> INVOICE# AMOUNT$ INVOICE# AMOUNT$ ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS n® F-► <br /> PREVIOUS MANIFEST CODE SEO# <br /> DOCUMENT ARE INCORPORATED HEREWITH MADE A PART HEREOF. ■ • (, <br /> CREDIT Print., visa U• N <br /> ARD Nam.: �: H�� O <br /> CREDIT CARD NO. _--__ AMEN EXP.DATE <br /> - Ml <br /> -' -EL'-LTL <br /> _ --- _- -- --T <br /> -I - 1 I_ MSA I i x ' ! <br /> llII _ GENERATOR/SHIPPER DESIGNATED REPRESENTATIVE SIGNATURE <br /> CUSTOMER REFERENCE I ��I ITIS I E (24 hours) <br /> INFORMATION <br />