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GUS FOMER'S COPY 1000 North Randall Road D -U -N -S 05106-0408 FE0. to N0.39-6090019 asElgin, iliinois 60123-7857 MANUALORDERFORM 0"-ftlun. KA 91 (141 C 7 — IM —01 M13 UCUSTOMER NUMBER S T, NAMPR- 0 M 2710 Lowis PD. E • ADDRESS R1 CITY ZIP CA 95M ZIP SERVICE DATE I SALESMAN'S NO. I SPECIALIST CUSTOMER P.O.NUMBER U ;lTjlliS I MANIFEST NUMBER CUSTOMER NUMBER NAME • ADDRESS CITY/STATE ZIP SALES TAX EXEMPTION NO. SERV. TAX C.....S TAX% PROD. TAX % -C PROD. SERVICE SALES TOTAL SERVICE SERVICE NO. SERIAL NO. TER CHARGE TAX CHARGE CHANGE SOLVENT INV C=GTEERM SCHEDU — SER (YY LED DATE REMARKS (WEEKS) (INITIAL) WW) CLEAN SPENT GODE� 14 1 -QXZ9 R El co MACHINE PROPERLY GROUNDED E SECTION & CLEANLINESS SERVIC❑E FUSIBLE LINK❑ ❑LOCAL&HONE NO. STICKER 0 , LI LAMP ASSEMBLY CHECK APPROPRIATE BOXES ON RIGHT) ---> ❑EMERGENCY INSTALLED CLOSING ❑ACCEPTANCE AFFIXED TO MACHINE SPENT SOLVENT MEETS r7i El (PLEASE CONDITION OF LID UNOBSTRUCTED TOTAL MACHINE CONDITION 1 1 11-6 GOOD POOR DECALS IN PLACE ca— AND LEGIBLE 0 El co MACHINE PROPERLY GROUNDED E SECTION & CLEANLINESS SERVIC❑E FUSIBLE LINK❑ ❑LOCAL&HONE NO. STICKER 0 , LI LAMP ASSEMBLY CHECK APPROPRIATE BOXES ON RIGHT) ---> ❑EMERGENCY INSTALLED CLOSING ❑ACCEPTANCE AFFIXED TO MACHINE SPENT SOLVENT MEETS r7i El (PLEASE CONDITION OF LID UNOBSTRUCTED CRITERIA �:" USEPA CORPORATE BRANCH GENERATOR USEPA 10 GENERATOR STATE ID NO. TRANSPORTER • DIN ILD98490820 21�Iof (� 1 39W J (L %47) US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME, HAZARD CLASS, AND ID) CONTAINERS NO. TYPE TOTAL QUANTITY UNIT WTNOL SK DOT NUMBER I certify that my total waste streams are within one of the following Waste Combustible Liquid, N.O.S. (Petroleum Naphtha) SSPW AND/OR 16 GAL. DRUMS 501 categories: NA1993 PGIH (EPA, D001, D018, D039) (ERG #27) RQ Waste Combustible Liquid, N.O.S. (Petroleum Naphtha) 30 GAL. DRUMS NA1993 PGIII 585 -o (EPA, D001, D018, D039) (ERG #27) 220 LBSJIMONTH RQ Waste Compounds, Cleaning Liquid, (Monoethanolamine) PRODUCT 566 INITIALS 8,NA1760 PGII1 (EPA, DOOG, D007, 0008, 1)021, D027, D039, D040) (ERG #60) N0.699 220 LBS. TO 2,200 LBS./MONTH INITIALS Combustible Liquid, N.O.S. (Petroleum Naphtha) 557 NA1993 PGIU (ERG #27) (NOT USEPA REGULATED) GREATER THAN 2200 LBSJMONTH_ INITIALS DESIGNATED FACILITY NAME AND ADDRESS: --ii Corp —fety He- USA EPA ID No. GARJ99fli-Ow W SaUda Blvd Salich CA 95n, STATE ID No. I i III, I I PRODUCT NUMBER DESCRIPTION MSDS DEALER UNIT OF GIVEN PRICE MEASURE QUANTITY DELIVERED SALES AMOUNT TAX LINE TOTAL El CASH LJ TOTAL RECEIVED APPLY PAYMENT TO: TOTAL SERVICE AMOUNT (FROM ABOVE)„ CHECK NUMBER El TODAYS SERVICE/SALE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS El PREVIOUS BALANCE AS FOLLOWS OTHERWISE INDICATED IN THE PAYMENT RECEIVED I TOTAL DUE, - SECTION, THE RECLAMATION AGREEMENT, ADDITIONAL TERMS AND CONDITIONS, AND OTHER INFORMATION INV. # AMOLINT$ — APPEARING ON THE REVERSE SIDE ARE MADE A PART HEREOF. THE ABOVE AMOUNT IS SUBJECT TO AN INTEREST INV.# AMOUNT$ CHARGE OF THE LESSOR OF lYi% PER MONTH (1181/6 PER IN THE EVENT OF DEFAULT, SAFETY-KLEEN SHALL BE ANNUM) OR THE MAXIMUM RATE ALLOWED BY LAW ON ANY ENTITLED TO RECOVER COSTS OF COLLECTION, INCLUDING INV: # AMOLINT$ UNPAID INVOICES THAT ARE NOT PAID WITHIN 30 DAYS. REASONABLE ATTORNEYS FEES. " 'This is to certify that the above-named materials are property classified, described, pack ed, marked a labeled, and am in proper condition for transportation •according to the appkable regulations of the Department of Transportation! I I 0111W�� PR I N�T �\\j NAM ['OLET6,k�91Eii FIS, 960604mPoRtANi NIF 06k] GENERATOR/DESIGNATED REPRESENTATIVE SIGNATURE <� PART NO 13 2 (REV 2/94)