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r <br /> 1 <br /> FORM ERA-LZ <br /> CSG SK-SSL-UMO-01 Joseph R Lima Jr 12/04/15 15:07 PAGE I - <br /> D <br /> M Safety-Kleen Systems, Inc . <br /> 2600N Central Expy, Suite 200 <br /> 0 Richardson, TX 75080 <br /> -n CORPORATE: 800-669-5740 <br /> 24 HR EMERGENCY: 800-468-1760 (Safety-Kleen) <br /> 2095451011 <br /> REFERENCE NBR. <br /> CUSTOMERS ST37139 Stockton Dodge 68679739 <br /> 3333 Auto Center Cir SRVC WEEK: 2015-49 <br /> Stockton CA 95212-2837 SRVC DATE: 12/04/15 15:07 <br /> PHONE 441-000-3000 <br /> BILL TO CUSTOMERS BILL TO ADDRESS: <br /> ST37139 Stockton Dodge <br /> 3333 Auto Center Cir <br /> Stockton CA 95212-2837 <br /> PHONE 441-000-3000 <br /> PURCHASE ORDER# TAX EXEMPT# <br /> PRODUCT/SERVICES <br /> SERVICE/ TOTAL <br /> PRODUCT QTY UNIT PRICE TAX CHARGE <br /> 66636 USED OIL NON-PREQUAL SERV 270.000 25.0000 0.00 2S.00 <br /> SERVICE TERM 1 WEEK <br /> HALOGEN / CLOR-D-TECT TEST RESULT PASS: PPM < 1000 <br /> TOTAL SFRVICE/PRODUCTS 25.0000 0.00 25.00 <br /> C TOTAL CHARGE 25.00 <br /> M CREDITS 0.00 <br /> T TOTAL DUE ---____25_00_- <br /> .Di <br /> Cl) UNPAID BALANCE THIS RECEIPT 25.00 <br /> M <br /> O <br /> _ If high risk source. SK rep. certifies that load specific PCB 0 <br /> M Silicon testing have been completed prior to pumping this load. <br /> GENERATOR STATUS <br /> SQG/LQG: Vehicle <br /> Customer certifies that (i) the above-named materials are properly <br /> classified, packaged, narked and labeled, and are in proper condition <br /> for transportation according to the applicable regulations of the <br /> Department of Transportation and (ii) no material change has occurred <br /> either in the characteristics of the waste/naterial or in the process <br /> Tgenerating the waste/material. Customer agrees to pay the above <br /> T charges-and to be bound by the terms and conditions (1) set forth in <br /> Z (a) the General Terms and Conditions provided separately to Customer <br /> a <br /> c or (b) any SK agreement signed by Customer and SK, and (2) <br /> m incorporated herein by reference. Unless otherwise indicated in the <br /> Payment received section, SK is authorized to charge Customer's <br /> S30InH3SWV483d <br /> account for this transaction. If Customer fails to make payment when <br /> H11V3H1VJMINNOWAN-.:, due, an amount equal to the lesser of (i) 1.S% per month (18% per <br /> annum) or (ii) the maximum amount allowed by law, will be added to all <br /> unpaid amounts outstanding. Customer certifies that the individual <br /> signing this Service Acknowledgement is duly authorized to sign and <br /> S10 7 T rJ �1 7 a bind Customer. The following provision is applicable to Safety-Kleen's <br /> 6 l b J] W m <br /> m � . <br /> (1PD <br /> ' Cn C e <br /> t <br />