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BILL Of LADING/MANIFEST 1.Shipper's US EPA ID No(If Applotable) 0 1�u p t o. 2 page 1 <br /> CAL000087982 of 1 <br /> ill 3.Shipper's Name and Mailing Address San I PakTRE <br /> Po Box 1183 <br /> TRACY CA 95378-1183 <br /> a.Shippers Phone( 2099835-3104 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's Phone <br /> SAFETY-KLEEN SYSTEMS INC TXR000081205 972-265-2000 <br /> 7.Tranaporler 2 Com an Name 8. US EPA ID Number B,Transportees <br /> CLEAN Heptad RS ENVIRONMENTAL S C INC.MAD039322250 81-792-5000 <br /> 9.Designated Facility Name and Site Address 9J 10. US EPA ID Number C.Facility's Phone <br /> CLEAN HARBORS SAN JOSE <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE CA 95133 CAD059494310 408-441-09622 <br /> 11.Shipping Name and Description 12' ners 913. Unit <br /> HM 01 Type Quantity wwol <br /> a. UNIVERSAL WASTE LAMPS sr'- f 0v <br /> (FLUORESCENT LAMPS) CF P <br /> b. <br /> 8 <br /> H <br /> 1 C. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> SK SHIP# 22737121055 SAr.3574 <br /> 24H EMERG# 800-468-1760(CH-SK-TFI)-TRANS AUTH TO RETAIN ADD'L CARRIERS <br /> DOT/PRFL_ A. 14815/156056 B. C. D. <br /> A) NONE B) C) D) <br /> t � vu <br /> 2-q <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: T"1610 f10h b.-,am�sae ' ' o„ m— <br /> cond0onty Oon accoro Ta r�eM ii.erl dNe nid Tran <br /> Pnntedrryoed Name Manta Day rear <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION:I cerdfY tris materWls dasmaec abo on M.s form are not wtpea to federal regulations for Transpmtat I <br /> Pant ped Name 4�tn `Day veQ <br /> T 17.Transporter 1 AdmoMledgemerr of Receipt of Materials <br /> A Printed/Typed NameS V a AIL— Signature �f / / `n/ ye <br /> P <br /> 0 18.Transporter 2 AckknnaMedge nt of Receipt of Materials <br /> RSi a Day r <br /> T me ry(/r♦C- 4AATZ <br /> r'0 <br /> E <br /> R <br /> 19.Discrepancy Indication Space <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 /> 1 <br /> T <br /> Y Printecirryped Nary Signature m D� <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-9029'(03/2015) <br />