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1301 Gervais Street - Suite 300 �/ r
<br />Columbia, South Carolina 29201
<br />�a196�. CUSTOMER NO.
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<br />DUNS NO. 05-397-6551 FED. ID NO
<br />FOR SERVICE CALL BRANCH MANAGER'
<br />!a . 13 .TMJ ref A' ?' t 3 `0 Q 4 !'1. E
<br />9 _ C U S 0�`"
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<br />DOC. EXP. SCHEDULED
<br />SCHEDULED
<br />=HANDLING
<br />TAX CODE cOD E
<br />,SERVICE WEEK
<br />TERRITORY
<br />CONDITION
<br />DESIGNATED FACILITY NAME AND ADDRESS S A F ,' T Y L P N S Y T M S T INC.
<br />5,OSO SAL IDA, BLVD SAL1 DA CA 95368
<br />CLOSING
<br />CREDIT PREVIOUSBALANCE
<br />r CODE
<br />ACCEPTANCE
<br />BAL. OVER.i3O DAYS
<br />D
<br />❑
<br />-- BUSINESS. CHAIN OUTER
<br />SVC. P/C
<br />PROD. P/C
<br />TYPEj COUNTY
<br />1 SERVICE/
<br />DEPT
<br />$$
<br />A .'.. I«/114
<br />REMARKS/ QUAN. CHARGE
<br />F
<br />E ,,sem T `✓' ;. 'I'. T ;} 114 i. A c(S a ';J
<br />0 LOCATION. TAX EXEMPTION NO.
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<br />R
<br />c I8AS K4 s
<br />S ICI *TE
<br />SA!,0 itq. °
<br />CUSTOMER P.O.. NUMBER
<br />E
<br />CUSTOMER PHONE
<br />=HANDLING
<br />TAX CODE cOD E
<br />'ASSOC.
<br />CODE SERVICE TAX C.O.M.S. TAX
<br />PRODUCT TAX
<br />CONDITION
<br />DESIGNATED FACILITY NAME AND ADDRESS S A F ,' T Y L P N S Y T M S T INC.
<br />5,OSO SAL IDA, BLVD SAL1 DA CA 95368
<br />CLOSING
<br />❑
<br />ACCEPTANCE
<br />CRITERIA ® ❑ C3
<br />❑
<br />9
<br />LID UNOBSTRUCTED ,
<br />1 SERVICE/
<br />DEPT
<br />`,y r `` A'-
<br />REMARKS/ QUAN. CHARGE
<br />SALES TOTAL
<br />WASTE SOLVENT/DRUMS
<br />SERVICE CHANGE CHANGE INV. PROMO
<br />CC sERVICETERM SCN.wM
<br />MSDS
<br />GIVEN
<br />PRODUCT
<br />;,
<br />NI i J t ,_; ;,
<br />UNIT PRICE
<br />TAX CHARGE
<br />*OF
<br />MIN: CLEAN SPENT CONT. SK DOT
<br />TERM (WEEKS)(INITIAL) OY Yrv0 CODE NO.
<br />1 1- rt ci i j
<br />�:) �1 /
<br />r y .� _ ( & ;;„ J
<br />, m � 9 3, c F e 14 �
<br />%B @�
<br />r� 01 � 9 -,
<br />&a as £„) .la 3''@ .C,i
<br />+day
<br />❑
<br />�99
<br />_�
<br />I1
<br />a!(, °°f.. '� J'
<br />�'�, /l� t.-._, - .--.90
<br />0 a Lt0S S R 8 0
<br />0,00 .
<br />0
<br />❑
<br />TP
<br />0 TO 220 LBS /MONTH„
<br />El
<br />3
<br />IT
<br />Z
<br />INITIALS
<br />El
<br />12
<br />El
<br />4
<br />TOTALS
<br />T -T i' .)'I +� e�'' CHECK
<br />�' x a :- s $ q
<br />,ix,,ea (; �>3 mak.:,' y3 APPROPRIATE MACHINE CONDITION
<br />BOXES &CLEANLINESS
<br />GOOD POOR
<br />DECALS IN PLACE
<br />AND LEGIBLE
<br />FUSIBLE LINK
<br />YES
<br />NO
<br />❑
<br />YES
<br />MACHINE PROPERLY GROUNDED I I
<br />LTJ
<br />LOCAL PHONE NO. STICKER
<br />AFFIXED TO MACHINE I
<br />NO
<br />❑
<br />❑
<br />z `
<br />W
<br />5
<br />-
<br />❑.
<br />6
<br />INITIALS- LU
<br />-
<br />- GREATER THAN 2,200 LBSJMONTH
<br />� Lr
<br />8
<br />a
<br />, ' -,
<br />(AI��IppyS}7Pt }OyA� q�ry } pr
<br />S � .s"0Bei050 {..iii
<br />j j [ r p.
<br />C A(„ OQ�0256 06
<br />11. US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.)
<br />USEDCLEANING COMPOUMN,
<br />LJ .: «EANGOMPOUM, L!6J TD (NOT .:;.SD TR
<br />URAED) AQUEOUS
<br />PARTS iA.HwR SOLUTION (8,,3 ,rAL„i+t, R %J
<br />SOLVENT MEETS
<br />CONDITION
<br />DESIGNATED FACILITY NAME AND ADDRESS S A F ,' T Y L P N S Y T M S T INC.
<br />5,OSO SAL IDA, BLVD SAL1 DA CA 95368
<br />CLOSING
<br />❑
<br />ACCEPTANCE
<br />CRITERIA ® ❑ C3
<br />❑
<br />9
<br />LID UNOBSTRUCTED ,
<br />12. R513.
<br />TOTAL
<br />1WiUNIT
<br />SK DOT NUMBER
<br />MY TOTAL
<br />CCONTAINP
<br />'.
<br />OL
<br />❑
<br />10
<br />WASTESTREAMSARE WITHIN
<br />ONE OF THE FOLLOWING
<br />CATEGORIES
<br />DM
<br />t R
<br />F-
<br />t2
<br />9 4 '1
<br />'i .XS
<br />11
<br />TP
<br />0 TO 220 LBS /MONTH„
<br />IT
<br />Z
<br />INITIALS
<br />El
<br />12
<br />TOTALS
<br />T -T i' .)'I +� e�'' CHECK
<br />�' x a :- s $ q
<br />,ix,,ea (; �>3 mak.:,' y3 APPROPRIATE MACHINE CONDITION
<br />BOXES &CLEANLINESS
<br />GOOD POOR
<br />DECALS IN PLACE
<br />AND LEGIBLE
<br />FUSIBLE LINK
<br />YES
<br />NO
<br />❑
<br />YES
<br />MACHINE PROPERLY GROUNDED I I
<br />LTJ
<br />LOCAL PHONE NO. STICKER
<br />AFFIXED TO MACHINE I
<br />NO
<br />❑
<br />❑
<br />z `
<br />W
<br />FPA Tt
<br />USTM-100050930
<br />a
<br />, ' -,
<br />(AI��IppyS}7Pt }OyA� q�ry } pr
<br />S � .s"0Bei050 {..iii
<br />j j [ r p.
<br />C A(„ OQ�0256 06
<br />11. US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.)
<br />USEDCLEANING COMPOUMN,
<br />LJ .: «EANGOMPOUM, L!6J TD (NOT .:;.SD TR
<br />URAED) AQUEOUS
<br />PARTS iA.HwR SOLUTION (8,,3 ,rAL„i+t, R %J
<br />SOLVENT MEETS
<br />CONDITION
<br />DESIGNATED FACILITY NAME AND ADDRESS S A F ,' T Y L P N S Y T M S T INC.
<br />5,OSO SAL IDA, BLVD SAL1 DA CA 95368
<br />LAMP ASSEMBLY
<br />❑
<br />INSTALLED
<br />SPENT
<br />SOLVENT MEETS
<br />CONDITION
<br />EMERGENCY
<br />CLOSING
<br />❑
<br />ACCEPTANCE
<br />CRITERIA ® ❑ C3
<br />OF
<br />LID UNOBSTRUCTED ,
<br />12. R513.
<br />TOTAL
<br />1WiUNIT
<br />SK DOT NUMBER
<br />MY TOTAL
<br />CCONTAINP
<br />'.
<br />OL
<br />-51612,01,55
<br />WASTESTREAMSARE WITHIN
<br />ONE OF THE FOLLOWING
<br />CATEGORIES
<br />DM
<br />t R
<br />F-
<br />t2
<br />9 4 '1
<br />'i .XS
<br />�
<br />0 TO 220 LBS /MONTH„
<br />Z
<br />INITIALS
<br />220 LBS. TO 2,200 LBS./MONTH Q
<br />-
<br />INITIALS- LU
<br />-
<br />- GREATER THAN 2,200 LBSJMONTH
<br />� Lr
<br />INITIALS ® G
<br />I CERTIFY, THAT
<br />NO MATERIAL CHANGE
<br />HAS OCCURRED
<br />USA EPA ID
<br />NO.
<br />C A
<br />y..� .� ,�.r'�= �___ -. ; Z a
<br />EITHER IN THE
<br />CHARACTERISTICSOF
<br />THE
<br />WASTEQ
<br />NO.
<br />`C A
<br />MATERIALS OR
<br />IN THE PROCESS GENERATING
<br />THE :STATE ID
<br />+ r= rI r,T i _.a, Y UJ v:
<br />sJ
<br />WASTE MATERIALS.
<br />_
<br />U K
<br />CASH , ; ❑ TOTAL RECEIVED APPLY PAYMENT TO:Bloom 1 AGREE TO PAY THE ABOVE CHARGES AND TO- BE BOUND BY THE TERMS AND TOTAL CHARGE u ;
<br />CONDRIONS SET FORTH ABOVE AND ON THE REVERSE SIDE THISDOCUMENT. (FROM ABOVE) r; s� >f-
<br />CHECKNUMBER. f_J �µ.. PLEASE CHARGE MY 'ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE
<br />❑ TODAY'S SERVICE/SALE ° INDICATED IN'THE PAYMENT RECEIVED SECTION. THE .INDIVIDUAL SIGNING THIS WASTE MIN.r^.,,(� a
<br />0
<br />n PREVIOUS BALANCE AS FOLLOWS LDR MESSAGE DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. (FROM ABOVE) x a J x
<br />INVOICE # AMOUNT $ INVOICE # AMOUNT $ prom B to oron that the e°9ation according "'amt are °fOParle °�w�d' packaged, marked arra labeled, arra are In
<br />, ' a.:. �,. - proper for transportation acwrdinO to the applicable re0ula6ons of the DeparlmeM ofTreneportaabn° TOTAL DUE
<br />I
<br />MANIFEST CODE SEQ # ¢ q ~�
<br />_.___ _._.. r.... _ .. ,_._......_...._....... __ __ �...-„. �.._.T ._._ `'�-' DO NOT WRITE IN THE AREA BELOW
<br />pry',,._. «�-�- �� .-,�... vna•.
<br />f Print Customer Name ✓
<br />CREDM CARD;s ,i
<br />AMEX,
<br />MO By.
<br />` `k ,r� Customer's,A sized Representative
<br />R REFERENCE ' �
<br />�
<br />
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