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A. <br />w <br />AW lqffi t Poem Drive- Buildho 2. Suite 100 800-669-5740 J DUNS NO. 05-397-6551 FED, ID NO. 396090019 <br />we 15 <br />Plano, Texas 75024 www.safety-kleen.com 1 <br />FOR SERVICE CALL <br />BRANCH MANAGER <br />DOC. EXP. <br />E D <br />SCHEDULED <br />ESCHEDUL E <br />ERVICE WEEK <br />EK <br />TERRITORY <br />CREDIT PREVIOUS BALANCE <br />CODE <br />CUSTOMER NO. <br />rt <br />---uA—Lc <br />USTOMER <br />OUTER <br />CHAIN SVC. P/c <br />PROD. P/C <br />SEGMENT <br />COUNTY <br />j <br />LOCATION TAX EXEMPTION NO. <br />SERVICE DATE SALES REP N0. CUSTOMER P.O. NUMBER <br />I CUSTOMER H�NE �# TAX CODE <br />DATE EOPT'PROD ORDERED I <br />SERVICE TAX <br />PRODUCT TAX <br />SERVICE/ REMARKS/ SALES TOTAL WASTE SOLVENTIDRUMS cc SERVICE CHANGE CHAR INV. PROM 0 <br />MSD! <br />DEPT QUAN. CHARGE TAX TERM SERVICE TERM KH, DATE C <br />PRODUCT UNIT PRICE CHARGE MIN. ODE NO. <br />CONT, SK <br />GIVEI <br />A" -------- <br />2 <br />f <br />El <br />El <br />-EJ <br />17-1 <br />CHECK GOOD POOR YES 140 YES NO <br />TOTAL-SERVICE/PRODUCTS APPROPRIATE MACHINE CONDITION❑ AND LEGIBLE ❑ <br />-] DECALS IN PLACE ❑F� m MACHINE PROPERLY GROUNDED ❑ED n <br />I.. <br />BOXES LOCAL PHONE NO. STICKER <br />& CLEANLINESS FUSIBLE LINK ❑ E:] AFFIXED TO MACHINE [I El <br />z <br />WNSTALLED <br />USEPA TRANSPORTER SPENT SOLVENT MEETS <br />USEPA TRANSPORTER 2 ID GENERATOR USEPA ID NO. GENERATOR STATE ID NO. LAMP ASSEMBLY 0 El <br />-1-IDINO. <br />EMERGENCY CLOSING o o El 0 <br />CONOMON OF LID UNOBSTRUCTED ❑ ACCEPTANCE CRITERIA <br />12, CONJAIYPEES <br />11. US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID.) NO. <br />T <br />113. TOTAL <br />0 UANTITY <br />14. UNIT <br />MNOL <br />SK DOT NUMBER <br />I CERTIFY THAT MY TOTAL <br />_ MS ARE WITHIN <br />WASTE STREAMS <br />UJI <br />ONE OF THE FOLLOWING <br />ONE <br />CATEGORIES. <br />0 <br />0 TO 220 LBSJMONTH <br />To 2. In '0 <br />IN=ITIALS <br />z <br />20 LBS. TO 2,200 LBS11,10 <br />2 .0 LEG To 2 <br />(j) <br />INITIALS <br />Uji <br />GREATER THAN 2,200 LOSiMONTH <br />(NITIALS <br />DESIGNATED FACILITY NAME AND ADDRESS <br />OCCURRED <br />I CERTIFY THAT NO MATERIAL CHANGE HAS OCCUSA EPA ID <br />NO. <br />z - <br />EITHER IN THE CHARACTERISTICS OF EWASTE <br />Uj! <br />MATERIALS OR IN THE PROCESS GENERATING THE <br />WASTE MATERIALS. STATE ID NO, <br />I <br />I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND <br />TOTAL CHARGE <br />CASH TOTAL RECEIVED <br />APPLY PAYMENT TO: <br />MANIFEST NO. <br />CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. <br />CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br />(FROM ABOVE) <br />> <br />CHECK NUMBER <br />❑TODAYBSeRVICEISAUEPLEASE <br />cc <br />PREVIOUS BALANCE AS FOLLOWS <br />INDICATED IN THE PAYMENT RECEIVED SECTION. THE INDIVIDUAL SIGNING THIS <br />WASTE MIN. <br />LDR MESSAGE <br />DOCUMENT IS DULY AUTHORIZED TO SIGN AND BIND CUSTOMER TO ITS TERMS. <br />�he 11 to calif y thre the llbo--M —,Iate we prhm� cl—ftd. 0�aged, —tholt taboW. 8� We In <br />(FROM ABOVE) <br />INVOICE # AMOUNT$ INVOICE # AMOUNTS <br />dit�'hl�Ith­Iee'Wmm—p� <br />NNW <br />TOTAL DUE <br />7 <br />PREVIOUS <br />MANIFEST CODE <br />SEO # <br />CREDIT <br />Print C'ustonter'Name <br />CARD NO <br />I <br />CRED[T-,CARD-NO,-,-- AMEX -,-EXP,. DATE <br />VISA <br />MC <br />0 <br />By: <br />Customer's Authorized Representative <br />CUSTOMER REFERENCE <br />INFORMATION <br />