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DUNS NO. 05106-0408 FED. ID NO. 39-6090019 <br />_ 1000 North Randall RoadE FOR SERVICE CALL TRANSPORTER <br />NIBBOa Elgin, Illinois 60123-7857 ;j� <br />2097545-1011 MONICA SHANNON <br />v — <br />j <br />SCHEDULEDSCHEDULED <br />SERVICE WEEK <br />TERRITORY <br />�� ' <br />M7CREDIT <br />CODE PREY. BALANCE BAL. OVER 60 DAYS <br />I <br />:1J <br />BUSINESS OUTER <br />TYPE CHAIN 'O TTT SVC. P/C PROD. P/C O <br />TAX EXEMPTION NUMBER <br />718501 U <br />SERVICEt DATE <br />ISALESREP NO. CUSTOMER P.O. NUMBER I CUSTOMER PHONE # HANDLING ASSOC. TAX CODE CODE CODE SERVICE TAX C.O.M.S. TAX PRODUCT TAX <br />SERVICE/ SALES TOTAL WM SOLVENT CHANGE OggrycE <br />DEPT - QUAN. CHARGE SERVICE ATI INV. PROMO <br />PRODUCT TAX CHARGE DISCOUNT CLEAN SP c NT SK DOT CC TERM S EEKS)(INITIAL (YY DVA'+) CODE NO. <br />MSDS <br />GIVEN <br />❑ <br />El <br />El <br />f <br />❑ <br />CHECK GOOD POOR YES <br />DEANLS IN DLEGIBLEPLACE ❑ <br />TOTAL-SERVICE/PRODUCTSAPPROPRIATE MACHINE CONDITION El <br />BOXES & CLEANLINESS FUSIBLE LINK ❑ <br />{ANIFESTNO. USEPA TRANSPORTER ID: NO. GENERATOR USEPA;ID NO. GENERATOR STATE ID'NO. � LAMP ASSEMBLY El [:1 EMERGEINSTALLED <br />y 0-* v V d l U CONDITION <br />1 i+ JJ Ar. A 4 OF UD UNOBSTRUCTED <br />NO YES NO <br />❑ MACHINE PROPERLY GROUNDED ❑ ❑ <br />LOCAL PHONE NO. STICKER <br />❑ AFFIXED TO MACHINE EJ ❑ <br />SPENT SOLVENT MEETS <br />❑ ACCEPTANCE CRITERIA ❑ ❑ <br />L. <br />Z <br />W <br />G <br />11. U—c DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, ANDr(D.) <br />12. CONTAINERS <br />NO. <br />TYPE <br />13. TOTAL <br />QUANTITY <br />14. UNIT <br />WTNOL <br />SK DOT NUMBERI <br />1 <br />S <br />CERTIFY THAT MY TOTAL <br />WASTE STREAMS ARE WITHIN <br />ONE OF THE FOLLOWING <br />CATEGORIES. <br />W <br />—j <br />rj <br />"-9 •-� '✓ _>._ T�S9 3 <br />1U7U G4 -1737t-77 i %GAL <br />0TO220LBSJMONTH <br />--DIM0 S T'I b L E - LIQUID, N.'�-CT. S:q'�.�.�1 �' &UtJ�tfi�-1d�� Pl'H'I'�4iA) NAI 991 <br />� p <br />SV V g W' <br />INITIALS <br />220 LBS. TO 2,200 LBS./MONTH <br />a <br />}� /� 7� syr �+y� ^ p <br />1TA II V D027, DV39DU}4V7t L+' R -G#128 <br />INITIALS <br />LU <br />Q� <br />to <br />Q <br />GREATER THAN 2,200 LBSIMONTH <br />INITIALS <br />81 miq <br />02 - <br />DESIGNATED FACILITY NAME AND ADDRESS SAFETY-KLEEN SYSTEMS, INC... <br />f 7 V ak 5 S I 1�, ' ti <br />USA EPA ID NO. <br />STATE ID NO. <br />Q- <br />W tCOo <br />_ CASH ❑ <br />TOTALi RECEIVED <br />APPLY PAYMENT TO: <br />I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND <br />CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. <br />PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br />INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS <br />DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. <br />"This is to ommy that the ataVe.amed maredais are pmpedy n—~ packaged. ma ed and IataWd, at,d ere m <br />proper ooadmaam,twsperWwa— gm maappfi blemgwana,:ofthe Depadme,lofTramtpodal .• <br />/^ <br />TOTAL CHARGE` <br />(FROM ABOVE). <br />WM DISCOUNTQ <br />(FROM ABOVE) <br />,. <br />V r <br />[— <br />[[ <br />Uj <br />_ CHECK NUMBER <br />- <br />. - e <br />❑ TODAY'S SERVICE/SALE <br />❑ PREVIOUS BALANCE AS FOLLOWS <br />LDR MESSAGE <br />INVOICE # AMOUNT $ INVOICE # AMOUNT $ <br />PREVIOUS __. <br />- <br />TOTAL DUE <br />MANIFEST CODE <br />SEO.# <br />CREDIT �_ <br />CARD NO <br />1 <br />12 <br />M7 2 2 2 8 <br />1333 <br />Print Customer Name <br />� <br />BEMERGENCY CUSt( s Authorized Representative T <br />C EDIT CrARL:'NO: <br />AMEX <br />f VISAIN <br />MC <br />EXP. DA <br />THE EVENT OF AN <br />CALLy: <br />1-800-468-1760 <br />nI <br />LJ <br />I l <br />CUSTOMER REFERENCE <br />[NFORMATION <br />THIS AGREEMENT CONTINUES O tHE REVERSE SIDE <br />