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1. Shipper's US EPA ID No. (If Applicable) Document N 12. page 1 <br />BILL OF LADING/MANIFEST ALr� 276 2 q C of 1. <br />3. Shipper's Name and Mailing Address M C NE ILUSS� TRUCKN <br />Pr!Med ffyp <br />C <br />•• <br />Gb. NON GULATED SHIPPER'S CERTIFICATION: I certify Via materals described above on this form are not <br />Ad Rd <br />Jill; 44dgmtoang <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />Stockton <br />CA <br />95215--2218 <br />Signatur <br />4. Shipper's Phone( 209-1931-4282 <br />R PrintedfTyped Name <br />T <br />5. Transporter i Company Name 5. <br />US EPA ID Number <br />A. Transporter's Phone <br />SAFETY—KLEEN SYSTEMS, <br />T <br />972-265-n210100 <br />7. Transporter 2 Company Name B. <br />US EPA ID Number <br />S. Transporter's Phone <br />9. Designated Facility Name and Site Address 7221 10. <br />US EPA IU Number <br />C. Facility's Phone <br />SAFETY—KLEEN SYSTEMS, INC. <br />6000 B8TIA STREET <br />SACRAMENTO CA 95828 <br />CA0000084517 <br />91.6-386-4913 <br />11. Shipping Name and Description <br />12. Cont finers <br />13. 14. <br />al Unit <br />HM <br />No. Type <br />Quantity wt/vol <br />a. <br />FLAMMABLE, <br />2a 1 <br />X <br />(UNIVEkSALRWASTE3 <br />Ir -1 <br />s <br />H <br />I c. <br />P <br />P <br />E <br />R d. <br />�r111rr.Ifrrrrrtrr� � <br />f raJ <br />IJt=Arr11 ryGCjAQThi <br />15. Special Handling Instruction and Additional Information l %d <br />'SK 10007042 <br />1) ERG#1.26 <br />24 HR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN — CONTRACT #94138) <br />SK AUTHORIZED TO }DETAIN LICENSER SUBSEQUENT CARRIERS AS NECESSARY <br />DOT/PRFL A. 19038/12400 B. C. D- <br />A) NONE B) C) D) <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION; '-diislocatransprtity rtneaewe rd[nAtr mad male <br />dlU. for trano ortaaan ecwrdfn to the c <br />Pr!Med ffyp <br />C <br />•• <br />Gb. NON GULATED SHIPPER'S CERTIFICATION: I certify Via materals described above on this form are not <br />PrintedfTyped Name <br />Jill; 44dgmtoang <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A Pi ted/Typed Na <br />N <br />5 <br />Signatur <br />P <br />O 18. Transporter 2 Acknowledgement of Receipt of Materials <br />R PrintedfTyped Name <br />T <br />Signature <br />E <br />19. Discrepancy Indication Space <br />1 .00-5-4 <br />to federal regulations for <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 />I <br />T <br />Y Rlinted/Typed Name -j� ��_. Signa <br />end labeled and are in Proper <br />Month Day Year <br />or disposal. <br />Month Day Year <br />Month Day <br />7. 1-7-1 1) <br />Month Day Year <br />ORIGINAL-RETUI Ti® GENERATOR FORM NO. 01.90291 (04111) <br />