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S <br />H <br />1 <br />P <br />P <br />E <br />R <br />1. Shippers US EPA ID No. (If Applicable) Document No. 12 -Pagel <br />BILL OF LAOINGIMANIFEST rnl���?:�Fk of <br />3. Shippers Name and Mailing Address MCNE I LUS TRUCK. <br />31.00 N -Ad Art Rd AUG 0 7 2015' <br />Stockton CA 952115--2218 <br />4. Shfppers Phone( 209-193_1-4282 ENVIRONRA <br />5. Transporter 1 Company Name 6. US EPA ID Number A. Transporters PhonINS TH s1r-pdRT4ACI <br />ii r'I:Y.rnJR tY.Th l.7 ?f'h C!7 J_'=r (__'_rlif 17r17Y <br />.I <br />7. Transporter 2 Compariy Name a. US EPA ID Number <br />B. Transporters Phone <br />9. Designated Facility Name and Site Address 7221 10. US EPA ID Number <br />C. Facility's Phone <br />SAFETY-KI_EEN SYSTEMS, INC. <br />6000 88TH STREET <br />SACRAMENT© CA 95828 CAO0.00084517 <br />916-386---4913 <br />11. Shipping Name and Description <br />12. Contliners <br />Total <br />Unit <br />—H—M-1 <br />No, <br />Type <br />Ouantity <br />VdVol <br />a. <br />IJN195101 AEROSI71_S FLAMMABLE, c. 1 <br />X <br />WWI VE� SAL WASTE <br />DM <br />� �� <br />P <br />b. <br />C. <br />d. <br />15. Special Handling Instrucflon and Additional Information <br />SK SIT'## 207.305674 10007042 <br />:'_4 HR EMEAGENCY #1-800-468-1760 (SAFETY-KLEEN - CONTRACT ##94138) <br />SK AUTHORIZED TO RETAIN LICENSED SL19SEQUENT CARRIERS AS NECESSARY <br />DOT/ 'RFL A. 19038/12400 S. C. D. <br />A) NONE B) C) D) <br />16a.U5DOTHAZARDOUSMATERIAL$SHIPPER'SCERTIFIGATION: TM'iste`°`ufyfalthe ab—named materials ampmpaVeloun�ca,ae:rnoen,perragea,memeuenniaawamefamProw <br />candilion fur trona Son accordl to ere eopkablewulatiom of the De rtm irtof TrimseZatim. <br />PrintedlTyped Name Month Aay Year <br />LATED SHIPPER'S CERTIFICATION: I certify the materiels desalbed above on this form <br />IName <br />1 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A Print yped Name Signature <br />N <br />S <br />o. 1a. Tr porter 2 Acknowledgement of Receipt of Materials <br />R Printed/Typed Name Slgnature <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />L 20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as noted in Item 19. <br />I <br />T <br />Y Printod/Typed Name Signature <br />ORIGINAL -RETURN TO GENERATOR <br />Page 4 <br />to federal arMi Sons far <br />or oisposal, <br />Month Day Year <br />Month Day Year <br />fT '� <br />Month Day Year <br />Month Day Year <br />FORM NO, 01-90291 (04111) <br />