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Columbia,South Carolina 29201 �a EOR SERVICE GALL y ! BRANCH MANAGER v DOC,EXP. SCHEDULED v vSCHEDULED <br /> }�v _'SERVICEWEEK .TERRITORY <br /> S7(fil�YIEEA• CUSTOMER NO: r <br /> 2.09-545-4 O :3 ERRY 'VANBERGE, 01 M 49450 <br /> C CREDIT PREVIOUS BALANCE <br /> $ CODE- BAL OVER SO DAYS <br /> _ BUSINESS CHAIN couNTY SVC.P1C PROD.P/C <br /> INA - - -0 <br /> • = LOCATION TAX EX MPTION NUMBER <br /> 18501 <br /> ' HANDLING ASSENT. . <br /> SERVICE DATE ALES REP N0. CUSTOMER P.O.PONUMBER CUS OVER PHONE# TAX CODE CODE cone SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> �EPt SERVICEt �+ - - SALES TOTAL CHLORINE TEST RESUt=T3 SK DOT SERVICE c�� cru"°E PROMO <br /> P UNIT PIiICL- QUANTITY CHARG(= - RALOUNTESTcE :Ctn.oR-aTEC7 CC SERVICE TERM.-SMDA-, RELEASE NO. <br /> ER TAX CHARGE11 NUMBER TERM ny.wyp NO. <br /> / r. PAW- FAIL RESUL7S(PPAi TESTeEsusrues h�E )fs+R1�2: <br /> � 41/1 <br /> 2 ET El <br /> 3� � ❑ <br /> 4 ❑ <br /> 5: ❑. ❑ <br /> s ❑ 10 <br /> 7 <br /> 8 ❑ ❑ <br /> 9 ❑ <br /> TOTAL-SERVICE/PRODUCTS - CAPACITY ANKTRANS•• - DATE ° /,r-- <br /> GENERATOR • • BOX r BELOW MANIFEST NO. USEPA TRANSPOfiTFR ID NQ--.- ��r- Xf/ <br /> f<- PRINT NAME SIGNATURE <br /> GENE-.Hhi OR VEHICLE. O-ti1ER '- } NO.PREQUAL REQUIRED,NO,HALOGEN TEST ICA ION ONI Y FLUIDS p s <br /> CI ASSIFIO <br /> HA7ARD WASTI_= Ft UIDS NO ICLL NO PREQUAL REQUIRED,HALOGEN TEST AT-PICK-UP DATE /f*Zs <br /> ` <br /> 3 PREQUAL REQUIRED,NO HALOGENTESTGENERATOR USEPA ID NO. GENERAIOR <br /> U <br /> CESQG El 1 El 3 4-PREQUALREQHiED,HALOGEiJTEST AT PICK-UP <br /> - <br /> - SQG/LQG JY2 ❑4 -*REFER TO REVERSE SIDE FOR DEFINITIONS (� - r g",f 1, <br /> PRINT NAME, SIGNATURE <br /> 11-US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,;AND ID.) 12.CNTTME' 13. TOTAL tu <br /> NO. PTTM � o sKDorNUMeFR <br /> t ? tq-RCRA H'ZA&:. OUS _Ag-TE (NOT .t€SDOT REGULATED) 11249 `I <br /> cic I <br /> 3. w i <br /> U- <br /> WC <br /> ?. 0 <br /> INTERMEDIATE F G�,ITY NAME AND ADDRESS S „gig ` <br /> # � :, �,�����-� f:r t° USA EPA ID NO. CC <br /> mss' " F' `'��"' Via•+_t ''3° �cd e5 ? STATE ID NO. �1 <br /> CASH ❑ - TOTAL RECEIVED APPLY PAYMENT TO: CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE TOTAL DUE O G <br /> CHEEK NUMBER INDICATED IU THE PAYMENT RECEIVED SECTION.. <br /> _ L]TODAY'SSERVICEISALE Cis[oaror certifies Drat the aW�e-rmmed maleriats ere pm{>arly c�a ilred_describetl,packaged,rtmked DO NOTVV9.TE IN T'r'1E ARE-3ELOYJ <br /> ❑PREVIOUS BALANCE AS FOLLOWS and wbek and am m proper wnmkm for vwnportabwt according to the appiiMWc reguk bom of the. <br /> AgM y aid U.S.Depwtnm(ewmrertakProtecaon ertt of Trar witilion. <br /> a� NvoIEE# U.S.E <br /> AFAOUNT$ INVOIEE# ANIOUNTs ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE.OF THIS M0007 4 9 450 <br /> DOCUMENT ARE 1N;CORPORATED HEREWITH MADE A PART HEREOF. <br /> PRCVIOUS MANIFEST <br /> _ _____..,�.�__ t G SEQ# - - <br /> CREDIT y - _ — PiR[ . . _ <br /> ARD NO I L Name—i\ D <br /> 005978 <br /> .E <br /> CREDII CARD NO AMEX EXP:DATE <br /> { VISA !- ? OF .v <br /> MC /� 1 6.1 v <br /> _ -.. ALL GENEVATORI SHIPPER DESIGNATED REPRESENTATIVE SIGNATURE <br /> FISTOMER REt`ERFNCt_ <br />