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2800 North Central mway,Suite 200 alety-kl800-BS9-5740 DUNSNO.05a97- 1 FED.IDNO.�eoaaol9 ELGIN OFFICE <br /> Richardson,TX 75080 www.sean.com ALL BRANCH MANAGER DOC.EXP.FOR SERVICE C <br /> IM�iIEEE CUSTOMER NO. _ DUL o scxsouLa <br /> t°< adB <br /> L Q I L{ IA 2 Z PREVIOUSBALANCE <br /> BIL OVER 60 DAYS <br /> s <br /> C _ '�a� •- �Cl faw 1 ENTCHAIN SVC.P/C PROD.P/C <br /> M T EaJE/�A C3 <br /> E LOCATION TAX EXEMPTIONNUMBER <br /> R <br /> SERVICE DATE SALES REP N0. CUSTOMER P.O.NUMBER CUSTOMER PHONE N' TAX CODE DATE EQPT/PiIOD ORDERED SERVICE TAX C.O.M.S.TAX PRODUCT TAX <br /> 'A-14-7,0 0MO <br /> SERVICE/ SURVEY SALE TOTAL CHLORINE TEST RESULTS SK DOT SERVICE wPWaE PROMO <br /> REPT UNITPRICE QUANTITY CHARGE CC sERNKa re%I a RELEASE NO. <br /> PRODUCT NUMBER TAX CHARGE aLORo-ra NUMBER TEgY TxEaxsl(rvmPi)m N0. <br /> b ❑ <br /> z ❑ ❑ <br /> 3 ❑ ❑ <br /> 4 ❑ ❑ <br /> S ❑ ❑ - <br /> 8 ❑ ❑ <br /> 7 ❑ ❑ <br /> B ❑ ❑ <br /> 9 ❑ ❑ <br /> TANK •r• DATE / a <br /> TOTAL-SERVICE/PRODUCTS - CAPACITY s <br /> •• • • :• • �f iaiS:= E Ql16f.1NL— X <br /> 7CESOG <br /> NERATOR: VEHICLE OTHER 1 NO PREWAL gEOUIREO,NO HALOT�� <br /> PRINT NAME SIGNATURE <br /> RDOUS WASTE FLUIDS NON-VEHICLE 2 NOPREOUALRECEIINED.—OOENst d� DATE <br /> 31flCATON' ONLY FLUIDS a PRECIUAI.REWIRED.NO HALOGENEP,K716PgEOUAI PEWPED,HALOpEN lEX <br /> SQG/LQG ❑2 ❑4 'REFER TO REVERSE SIDE FOR DEPRIM NAME SIGNATURE <br /> TT.US OOT DESCRIPTION(INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) - - - TOTOL T acoorxuueaR r 1 <br /> W 2 <br /> A. LL 'I I .w. C�7 <br /> m <br /> B. _. - - N w <br /> w0 <br /> D. U U <br /> IINT15FRIM DIATE FA ILZ NAME AN w <br /> USA EPA ID IN R W <br /> L STATE ID NO. O Q <br /> GOSH ❑ TOTAL RECEIVED APPLY PAYMENT TO: - CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE TOTAL DUE S DD <br /> CHECK NUMBER WDICATED IN THE=RECEIVED SECTION. <br /> ❑TOOAY59EANCESua nRIUPxV tlenn.awuxf.wnR9BN.mxb DO NOT WRITE W THE AREA BELOW <br /> ' ❑PREVp93 MLNICFA9 POLLDWS - ��m�mnaro�wvnR�U�a�M sgoCx mu4wAgM <br /> aJVOICE N AMOUNfd INYOICEN AMOUNTS STATE WASTE CODE 22E ADDITIONAL TFRNS AND CONDITIONS ON THE REVERSE SIDE OF THIS <br /> RE. <br /> _.._..-.. ........._.__._...__._____._._._____..___.___-.__.. MANIFEST CODE 8E0• DOCYM NTA IC RPORATED NE IITX MADE A PART XEREOF. <br /> lI ISI I-II US PM1K�' <br /> AMEX W1 <br /> VISA v <br /> CUSTOMER REFERENCE <br /> INFORMATION. SEE REVERSE SIDE FOR IMPORTANT INFORMATION - <br />