Laserfiche WebLink
BILL OF ADI NG�MAN1fiEST 1.Shipper's US EPA ID No.(if Applicable) gncumenttvo. 2 Page 1 <br /> EXEMPT - 738412 °t i <br /> 3.Shipper's Name and Mailing Address '� <br /> 1250 N Wilson Way <br /> Stockton CA", 95215--3145 <br /> 4.Shipper's Phone( 55622)G2 1-35B 1 <br /> 5.Transporter t Company Name 6. US EPA ID Number A.Transporters Phone <br /> SAFETY—KLEE.N SYSTEMS INC. TXR000050930"`. 972-265-2000 <br /> 7.Tg(tspofl r 2 Com nY N e V S_ - _- ( �U EPA I umbe, i 3 B.Transporters Phone <br /> rn -eh <br /> aSIZLf <br /> 73 <br /> 9.Designated Facility Name and Site Address 7241 10, US EPA ID Number C.Facility's Phone <br /> SAFETY—KLEEN SYSTEMS, INC. <br /> 2120 5 YALE ST 714--429-4300 <br /> SANTA ANA CA 92704 CAT0006i:�97E'} <br /> 11,Shipping Name and Description 12.Contliners 13. 14. <br /> (i <br /> MM Total Unit <br /> li No. Type Quantity Wt/VOI <br /> a- rON REGULATED LIQUID <br /> DM Pr <br /> b. 3; <br /> i <br /> H <br /> c. 7� <br /> P <br /> P <br /> E <br /> R d. I� <br /> I <br /> 15.Spatia!dandling Instruction and Additional Information p <br /> SK SHIP# 206238 73 3017606 <br /> 24 HR EMERGENCY #1--801-468-1760 (SAFETY—KEEN o — CCINTRACT #94138) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> DOT/PRFL A. 23136/3565088 Be C. D. <br /> A) NONE. B) C): D) <br /> i Ih <br /> 1Ba.USDOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -rh"ittooo'f,'tl,atthe a6avc-nameamet god,mated and ranewand are nprow <br /> oontliL'on fortress Van acardin to ns a tAa re ativ.y of the tae a+iment o(7ran erten. <br /> Printed/Typed Name l! iuonrn Day year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the mareria:s described above on this form are not subject to federal regui.Rbons for Transportation or Disposaf. <br /> s' Pri yped Name f Month nay Year e <br /> J a <br /> Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printedll Name , Signature � Month Day rYear <br /> P ar <br /> 0 <br /> 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T P t (gyp a yj _ Signature Montle Day Year <br /> R 1J� tl f► � C3 l <br /> 19,Discrepancy Indication Space f:�f <br /> F <br /> A - <br /> I <br /> L 20.Facility owner or Operator Certification of receipt of materials covered by this form except as noted in fiem 19. <br /> T <br /> Y Prinfedl3yped N Signature Month Day Year <br /> ko 'e4 <br /> ;rt r <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(04111) <br /> a� <br />