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BILL OF LADING/MANIFEST 1.Shipper's US EPA ID No.(If Applicable) Document No. 2.Page 1 <br /> 1:AL0004c2482 55180 of 1 <br /> 3-Shipper's Name and Mailing Address Heartland Express of Iowa Inr <br /> 12550 Harlan Rd <br /> LATHROP CA 953330-0000 <br /> 4.Shippers Phone( 8007426-601113 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporters Phone <br /> SAFETY-KL..EEN SYSTEMS INC I T.XR000081205 972-265-2000 <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> 9.Designated Facility Name and Site Address EVG 10. US EPA ID Number C.Facility's Phone <br /> SAFETY-KLEEN OF CALIFORNIA <br /> 6880 SMITH AVE. <br /> NEWARK CA 94560 CAD980887418 510-795-4400 <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WtNol <br /> a. NON-REGULATED LIQUID (VAC-OIL WATER <br /> SLUDGE) (NOT USDOT/NOT USEPA RGULATLD) TT G <br /> (NOT CA REGULATED) <br /> b. <br /> S <br /> H <br /> I C. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> SK SHIP# 28�l99 <br /> 24H EMERG# 800-468-1760(CH-SK-TFI)-TRANS AUTH T RETAIN ADD' L <br /> y <br /> DOT/PRFL A. 3299/156097 B. C. D. �„ r <br /> NONE B) C) D) 1910,LL``'�� <br /> This is to certify that the above-named materials are properly classified,described packaged,marked and labeled and are in proper <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPERS CERTIFICATION: <br /> condition for trans ortation accordin to the applicable regulations of Department of Transportation. <br /> Printed/Typed Name Month Day Year <br /> �• <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to federal regulations for Transportation or Disposal. <br /> Printed/Typed Name Month Day Year <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A fdnt d/Typed NameytALSignature Montq Day Year <br /> PL -eaN5 11 <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed ed Name Signature Month Da Year <br /> T YP 9 y <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> 1 <br /> T <br /> Y PrintedLTyped Name Signature / Month Day Yer1X, I <br /> r <br /> C� <br /> It <br /> noir lnlAI DCTI IDAI Trl r`_C1\IC0A-rn0 FORM NO.01-90291 (03/2015) <br />