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I <br /> BILL OF LADING/MANIFEST 1.Shipper's US EPA IDNo.(If Applicable) Document No. 2.Page 1 <br /> 3.Shipper's Name and Mailing Address Call West Concrete Cute Anq <br /> J.153 Vanderbilt Clr <br /> MANTECA CA 95337-61210 <br /> 4.Shipper's Phone( i:)i!1`))-L1c'..�'"►^�r'.i�i <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporter's Phone <br /> 9.Designated Facility Name and Site Address E'V6 10. US EPA ID Number C.Facility's Phone <br /> SAFETY'- KI-E E'N O CALIFORNIA <br /> 6880 SM.T 1'H AVE. <br /> NEWARK CA 94560 CAD980887410 510-•795--'44100 <br /> 11.Shipping Name and Description 12.Contliners <br /> 13. 14. <br /> Total Unit <br /> HM No. Type Quantity W <br /> a. NON— L,101..1 CD (VOC--'f.IRIE_ WATER <br /> `31.,UDGE) (NOT USDOT/NOT UfSEPA H:,Lh.E'- b) <br /> (NOT (tet'; RE011-I1.-ATED) <br /> b. <br /> S <br /> H - <br /> C. <br /> P <br /> P <br /> E <br /> R d <br /> , I <br /> 15.Special Handling Instruction and Additional Information <br /> SK FrH I11 3��.4914 :7 CA39985 <br /> 8 18 t 4{33f'S <br /> 24H EMERCr# 841O---468--176(6(CH--SK--'TFI ) -TRANS AUTH TO RETAIN ADD" L" CARRIERS f <br /> DOT/PRF=L A. 3299/156097 B. C. D. <br /> A) NONE D) C) D) <br /> I <br /> ( <br /> 16x.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -This is to certify that the above-named materials are properly classified,described,packaged,marked and labeled and are In proper I <br /> condition for trans orlation accordin to tLe applicable regulations of the Department of Transportation. <br /> Printed/Typed Name Month Day Year <br /> Be <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. i <br /> •' Printed/Typed Name _. e <br /> Month Day Year <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials r•° '!mfr <br /> A Pr'nted/Typed Name Signa re f <br /> N _ Month Day Year 1 <br /> fi t <br /> P <br /> WA AA <br /> 0 18.Transpo er 2 Acknowledgement of Receipt of Materials I. <br /> TPrinted/Typed Name Signature Month Day Year II <br /> R <br /> 19.Discrepancy Indication Space ' <br /> F <br /> A <br /> C <br /> I II <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 Printed/Typed Name Signature Month Day Year <br /> I <br /> 24 HR EMERGENCY <br /> 800-468-1760 i <br /> GENERATOR'S COPY FORM NO.01-90:291(03/2015) <br />