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BILL OF LADING/MANIFEST 1,Shipper's US EPA ID No.(If Applicable) Document No..l, 12.Page i <br /> EXEMPT . 73842 of 1 <br />! 3.Shipper's Natrie and Mailirig Address i' <br /> 1250 N Wi).SO" WaY <br /> Stockton CAF 95205-3145 <br /> 4.Shippers Phone, V ---3581 <br /> 5.Transporter 1 Company Narhe','' fi. ' US EPA ID Number; t A.Transporter's Phone <br /> r <br /> SAFE 'Y ,KLEEN`;SYSTEMS iNCa TXR000050930 972•--265--2000 <br /> T.Transporters Compahy Name' $, US EPA tD Number B,Transporter's Phone <br /> 3 <br /> 9 DestgnatecfF�acdlty Name -d'Site Address 72; 4 10, US EPA ID Number.i C.Facility's Phone <br /> SRFEfi Y KLEEN 'SYSTEMS INC. <br /> 10 ►2 HIC�C50N ST <br /> CA 51.731 CAT000613893 It 626--401-2616 <br /> 1�1 $htpp7ng Name and Description 12.ConF rnars 13. 14 <br /> 1 1, Total Unit <br /> ;HM t ib No. Type Quantity wtNot <br /> REGULATED SOLID <br /> DM P <br /> V <br /> 3y. � <br /> dS <br /> ' �l <br /> u �P <br /> w` <br /> a <br /> r 15 Speciat Handling Instnrction and Additional information ;{ 4 <br /> K SK SHIP# 20623843T/ <br /> g �4 HR EMERGENCY #1-800-468--1760 (SAFETY--KLEEN CONTRACT #941:38) <br /> 5f :, RUTHORI ZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> - <br /> r i D 1T%PRFL A. 25383/3565087 B. C. Da ;r <br /> & a <br /> A), NONE B) C) D) <br /> nl <br /> 1 W � <br /> Q2h <br /> 'I6btUSDOTHAZARDOUS MATERIALS SHIPPER'$CERTIFICATION: T sletorsrttlythat the atwve.namedmetelaisAre popenyuassned,descried,packaged,makedeMlabeled and are nproper <br /> condition for trans ortation acwcfna to thea polcobte reA Walions of the De anmanl of Tram [Ion. <br /> 1 vr Pri;ztedlTyped Name I' Month Day Year <br /> 9 <br /> NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form ara not Subject to federal regulations for Transportairon or disposal. <br /> • r P i lfyped Na ; <br /> e .. Month Day Year <br /> T 177 Transporter 1 Acknowledgement of Receipt of Materials <br /> A int' !Typed Name S197 M th Day Year <br /> P <br /> of `1 Transporter 2 Acknowledgement of Receipt of Materials <br /> R' Prime <br /> T y me Signature ' <br /> E � 0LAL Moo]nth ?Day Year 11 1a i <br /> 19.Discrepancy Indication Space <br /> E` F <br /> �A <br />� 4 C <br /> ., 20.Facility Owner or Operator.Certification of receipt of materials covered by this form except as noted in Item 19. <br /> Y Printed/Typed Name <br /> � Signature - Month Day Year <br /> Ijmill, <br /> 3 <br /> • <br /> 7. <br /> GRI a1NAL_ RETURN TO GENEiATC�C� FORM roe.01-90291(04111) <br />