Laserfiche WebLink
11/«36/2008 11:11 2094682 CLEAN HARBORS PAGE 03/03 <br /> CleanHar bors <br /> ON <br /> ENVIRONMENTAL SESVICESS <br /> INY CE f AUT QR T10 ge CREDIT CARD BILUrie <br /> Date: WA.7�-Q8 <br /> To: Clean Harbors Environmental ServiceDn A4 <br /> 04 <br /> Fax: SA000048 <br /> Phone:781^792-5249 <br /> From: Name: Account#Number. <br /> Com n .San Joaquin Coup Parr Ii<Rec Tele hone: 209-331 2048 <br /> Mailir� Address: 11793 N . Mike Grove Rd. _ Fax: - --- <br /> CState:,,. Ze Code: 95240 <br /> This is authorization to Pay tate follomng Clean Har[x�InvolceW <br /> Invoice Number Elate Amount Invoice Number Date <br /> Amount <br /> 10-9-06 93.56 <br /> Total Charges to be applied to Credit card will be for tha following amount $_93.56_ <br /> VISA MASTERCARD AMERICAN EXPRESS INVOICE CHECK_ <br /> PIN# CHECK# <br /> No Yes <br /> If yes,what is the amount?$ <br /> Name as it appears on Card: Hugh Mullen <br /> Company Name: <br /> Card Billing Address: ,fit r� Sao J Wq u 1 n �'t- <br /> Credit Card Number: _ v '3 6(Z- <br /> Card Authorization mate: <br /> Authorization Signature; <br /> RETURN RECEIPT BY: FAX U.S.MAIL <br /> k I Cal <br />