Laserfiche WebLink
1301 Uervals 5'treet-z5urte juu - <br /> Columbia,South Carolina 29201 FOR SERVICE CALL BRANCH MANAGER DOC.EXP. SCHEDULED SCHEDULED <br /> SERVICE WEEK TERRITORY = ' <br /> Iil�ilESB. CUSTOMER NO. Q X12 Q}'RRES <br /> R CODE PREVIOUS BALANCE BAL OVIEWDAYS- <br /> BUSINESS OUTER <br /> TYPCHAIN 22UNT SVC.P/C 1,,*D.P/C <br /> LOCATION TAX EXEMPTION NUMBER ?i <br /> • � <br /> SERE V D E SALES REP NO. CUSTOMER P.O.NUMBER CUSTOMER PHONE# TAX CODE ODE HANDLING coo' SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> SALES TOTAL CHLORINE TEST RESULTS SK DOT SERVICE CHANGE CHANGE PROMO <br /> DEPT SERVICE/ S tAL UNIT PRICE QUANTITY CHARGE HALOGEN CHLOR-D-TECT NUMBER CC TERM SERVICETERM syy.WW) NO. RELEASE NO. <br /> PRODUCT TAX CHARGE PASS FAIL RESULTS PP TESTOS MffWA S (WEEKS)(INITIA <br /> ❑ ❑ <br /> ❑ / <br /> 4' aUr ❑ <br /> ❑ ❑ Ah <br /> ❑ ❑ <br /> ❑ ❑ <br /> TANK❑ :L9131 DATE / <br /> TOTAL-SERVICE/PRODUCTS - CAPACITY4A 2, <br /> o <br /> RINT NAME IGNATURE <br /> JR <br /> GENERATOR:'. VEHICLE , OTHER"`, 1 NO PREQUAL REQUIRED,NO HALOGEN TEST ) R Q 0 0 O 5 U 9 3 0 , DATE / / c O <br /> HAZARDOUS WASTE FLUIDS NON-VEHICLE 2 NO PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP g Z <br /> CLASSIFICATION* O FLUIDS' 3 PREQUAL REQUIRED,NO HALOGEN TEST <br /> CESQG 1 ❑3 4 PREQUAL REQUIRED,HALOGEN TEST AT PICK-UP �} X a <br /> SQG/LOG ❑2 ❑4 'REFER TOREVERSE SIDE FOR DEFINITI(SIS �` lt(.�() . PRINT NAME SIGNATURE <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) 12. . I TYPE <br /> 13. TOS; ta.VOIL SK DOT NUMBER F. <br /> WZ <br /> CN--RCRA HAZARDOUS WASTE LIQUID COIL, WATER SLUDGE( NOT DDI' � 1 � 3287 / 1. .\ <br /> ., W <br /> 0C.)VL <br /> LLl a :. <br /> INTERMEDIATE FACILITY NAME AND ADDRESS SAFETY-KLEEN SYSTEMS INC /'� USA EPA ID NO. cc W <br /> STATE ID NO. J <br /> OQ <br /> CASH ❑ TOTAL RECEIVED ]AAYMENT <br /> TO: CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE TOTAL DUE N <br /> CHECK NUMBER INDICATED IN THE PAYMENT RECEIVED SECTION. <br /> ❑ flVICE/SALE qA,t ttNi the abwarsrrned medals are properly dassrfieL de�dtsd.paled marked DO NOT WRITE IN THE AREA BELOW <br /> ❑ ALANCE AS FOLLOWS ard labeled,and are In proper confton for baspotabon axodng to Alta applicable regUallos of the <br /> U.S.ErMrarrattal Protection Agency and tis U.S.Departrrsnl of Transportation. <br /> a INVOICE# AMOUNT$ INVOICEAMOUNT$ ADDITIONAL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS M00201923.4 <br /> ® MANIFEST CODE SEO# DOCUMENT ARE INCORPORATED HEREWITH MADE A PART HEREOF. <br /> PREVIOUS Print 1!` vis* <br /> CREDIT <br /> 001333 <br /> ARD NO CREDIT CARD NO: EXP'D \\. • j <br /> ;::, ' GENERA ORISHIPPER DESIGNATED REPRESENTATIVE SIGNATURE <br /> CUSTOMER REFERENCE I TT I I I I I I I I .r 01C= vl= O <br /> c ocDeclnF CIV <br /> r)la IAAPnPT® T wr:nPmATinN <br /> :�� <br />