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—.V ouu-obit-0/4u <br /> Piano,Texas 75024 www.safety-kleen.com FOR SERVICE CALL BRANCH MANAGER <br /> -1 <br /> 4 5 R—FIFN 37PP,✓-44-,4-'; 0�; ',;-i <br /> J ........ DUNS NO.05-397-6551 FED.ID NO.396090019 <br /> NAME TITLE SIGN <br /> NAME GENERATOR LOCATION NAME BILL TO(IF DIFFERENT FROM LOCATION) 1, <br /> HA' B 2. r Fry <br /> L.0 <br /> DE Ef i r x- DE RY ADDRESS ., yap <br /> Cf) <br /> 21J51 1 1 1 1 1 1 1 1 1 11 <br /> NAM' <br /> JDE- <br /> INFORMATION/ATTENTION LINE SIC CODE <br /> , I I I I i I I IILLL= <br /> CITYASTATE C &TATE, BU INESS CHAIN:J�j SVc0ftf//b <br /> FIE' P/C <br /> ZIP <br /> RE' AR r TY <br /> ZIP T CODE ZIP <br /> illpfR UNIT PflCf I I I TAX CODE SALES TAX EXEMiAfldNlWbAAMR NO. <br /> -1- 1 -1-1 -1.71 P-7 I Ll [l I I <br /> 5 0. 00 <br /> ,qA <br /> -%AkF$REDKC�J���To C40DE OBLANKET 1:1 TEMPORARY CUSTOMER PHONE NO. G C.O.M.S.TAX I PRODUCT TAX <br /> , <br /> MER'S SERVICE TAX <br /> V)6/NUMBER 1 166. 75 12, 9,L 1'7'x. 67 0. 00 1 94 8 1 AlL <br /> E1151RE m mosimummm EM <br /> SERVICE/ IAL SALES TOTAL SOLVENT/DRUMS C � — "I-cm, <br /> DEPT, REMARKS/UNIT PRICE QUAN. CHARGE 'C SEFmCr= FREE PROW RELEASE s <br /> PRODUCT NUMBER TAX CHARGE CLEAN SPENT ;�4, SK DOT TERM w TIM CN NO. NO. N <br /> 14;11 _9 9j <br /> I -q6 7 <br /> El <br /> El <br /> El <br /> TOTAL-SERVICE/PRODUCTS 374. 90 12, 9�' 1,tk 8 2 0. 00 REFUSED SERVICE EXPLAIN <br /> (I)NLAVAPPUCATION <br /> (2)REPLACE DEFECTIVE MACHINE <br /> ............... PLACEMENT(2) <br /> REPLACE COMPETITIVE MACHINE <br /> USEPATRANSPORTERAJD,N 0- CODES, (4)REPLACE HME MADE VAT., <br /> (S)ADDITIONAL.MACHINE <br /> GIVE <br /> 1:1 <br /> El <br /> El <br /> THR0000 ()2:30 CAL000256206, <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) 12.CONTAINERS 13. TOTAL 1,4T'UN IT I EE; <br /> CERTIFY THAT MY TOTAL <br /> SK DOT NUMBER AST <br /> NO. TYPE QUANTITY g 3-El WASTE STREAMS ARE WITHIN <br /> ONE OF THE FOLLOWING <br /> USED Cf,EANING COMPOUNDS, Ll1)UID ( NOT U",'DOT OR G 11 ATE <br /> USEPA REGULATED ) AOUE,011S PARTS WASHER SOLUTION 8, 34GAL To MONTH <br /> 71 NfF I/A—LI— <br /> .0 LBS.TO 2,200 LBS./MON <br /> INITIALS <br /> GREATER THAN 2,200 LBS./MONTH <br /> INITIALS <br /> DESIGNATED FACILITY NAME AND ADDRESS S USA EPA ID NO, <br /> ,AFETY -ELEEN SYSTEM"`, INC. CAT0006 7b8 <br /> — <br /> t'�050 SALTDA SAI, DA CA 95368 STATE ID NO. c Au(757 177 F <br /> CASH El TOTAL RECEIVED APPLY PAYMENT TO: 0 <br /> gp I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE z <br /> CHECK NUMBER CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) 177 <br /> ❑TODAY PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br /> ❑ 'S SERVICE/SALE INDICATED�N THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS <br /> PREVIOUS BALANCE AS FOLLOWS LDR MESSAGE DOCUMENT S DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. TOTAL DUE z- (L <br /> INVOICE# ? <br /> 'ThIs Is"cre*"I ft ab--d rresIsdalIr m WcPwIY oleselfied Padmad,mrked and labeled,and m In DO NOT WRITE IN 7RE­A BELOW <br /> AMOUNT INVOICE# AMOUNT 'LDR 140T REQ 'D proper condflon for tremporkatim according to Iha appIlcalle regulettom of the Deparbm t of TwspDrWfiDn.- <br /> MANIFEST CODE <br /> PREVIOUS SEQ# <br /> CREDIT <br /> CARD NO 0906 ID 3 D Print (isto'm'er-Narne <br /> L;111=Dl I CARD NO.J <br /> - AMEX • 0028721735 <br /> VISA • <br /> MC By: <br /> 11040 Cust6Ter'sAuffikied Representative <br /> CUSTOMER REFERENCE FT-T7 FTTTT <br />