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BILL OF LADING/MANIF <br />� <br />ST 1. Shippers US EPA ID No. (If Applicable) Document No. <br />2. Page 1 <br />-4P <br />of <br />3. Shipper's Name and Mailing Address' <br />1-411 tit` CURID., <br />,Jj-,-JILL <br />47 E MARTIN' LUTHER' K I t,10 B LA) D <br />"I -SC KTON C -A 1375;2105 <br />4. Shippers Phone( <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />A. Transporter's Phone <br />SAFETY RLEEN 9Y3*MS. INC. I T: �V)0- 1 a 0 5 VT3 26 1-,1 <br />972-265-2000 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />B. Transporter's Phone <br />9. Designated Facility Name and Site Add' ss 2;H� 7 1 10. US EPA ID Number <br />C. Facility's Phone <br />SAFETY--KLE EN SY T =MS, INC. <br />60001 88TH STREET I <br />SACRAMENTO C� 95828 -.1eA00000845 1 7 <br />. . . . . . . . . . <br />11. Shipping Name and Description <br />12. Containers <br />13. <br />14. <br />Total <br />Unit <br />F—HM-1 <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />J <br />b. <br />S <br />H <br />I <br />C. <br />P <br />P <br />E <br />R <br />d. <br />15. Special Handling Instruction and Additional Information <br />SK 5,H1 P# 204'332977 <br />371838 <br />E'!4 HR EME.---RC-3ENC� (---3AFE'TY—KLEEN <br />CONTRqCT #94138) <br />'AUTHOR—ZE', RETAIN LICENSED SUBSEQUENT CARRIERS AIS NECESSf-"IRY <br />;0 <br />D�Ff/FiRP., A :, -1 .44, E -V150167 D. C11 D <br />P NONE <br />'This Is to certify that the above -names materials are properly classified, described, packaged, marked and labeled and are in proper <br />16a. US DOT HAZARDOUS MATERIALS SHIPPERS CERTIFICATION: condition for vans nation ccordinq tothea ppikcable requiatio s of the Department of Transportation <br />Printed/Typed Name <br />I I <br />Month Day <br />Year <br />16b. NON-REGULATED SHIPPER'S CERIFICATION: I certify the materials described above on this form are not su�ect to federal regulations for Transportation or Disposal. <br />dFryped,Name <br />Month Day <br />Year <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Prin�typed Name/2 <br />Signature <br />Month Day <br />Year <br />N <br />S <br />*I <br />P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day <br />Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator: Certification <br />f receipt of materials covered by this form except as noted in Item 19. <br />T <br />Y <br />Printed/Typed Name <br />Signature <br />Month- Day <br />Year <br />