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f <br /> 1.Shipper's US EPA ID No.(If Applicable) Document+No. 2 Page 1 <br /> f BILL OF LADING/MANIFEST -- - ' of <br /> ial- I�I�fIA ti 1 t♦I'r'/a�I . I .L:- <br /> 3.Shipper's Name and Mailing Address )ti''-')••'"Ol O O+'1 '-'e r V L c e <br /> TRACY CA 9.5 31214-•0000 <br /> I <br />� 4 Shipper's Phone( <br /> i 5.Transporter 1 Company Name 6. US EPA ID Number A-Transporter's Phone <br /> II AFF'C'Y—KL.EEN SYSTEMS INC <br /> 7.Transporterm 2 Coan Name 8. US EPA ID Number B.Transporter's Phone <br /> CLI pN !t i( CiVORS ENV SVC INC. MAaDO393322250 788 -'792-5000 <br /> 9.Designated Facility Name and Site Address AG 10. US EPA ID Number C.Facility's Phone <br /> i A-ZAN HARBORS AW.)GC7NITE' )__L( <br /> 11600 NORTH APTUS 00AD <br /> 1 <br /> ARAGONITE IJT 84029 UT(98 i 5".-;21 r 7 435-8a4-8100 <br /> I ' <br /> E 11 Shipping Name and Description 12.Containers 13 14. <br /> Total Unit <br /> HM No. Type Quantity Wt Vol <br /> a. LIN19.50 f-iFRO�iI-IL.- F[.,.AVII�lABLE Nn Oe .S t <br /> X c�� 1, UNIYERSAi_ WhSTC .- AER(]S C_ CAN CS DM ' <br /> b. <br /> S <br /> H <br /> c- <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> SK SHIP # r.- E+1I:;6::°6518 <br /> 1 ) Ef2(.i#126g37 vtct(M�� <br /> 24H EW...RG# f 00--'4r-8-•1760((--H-•SK—TC=I) —TRPN6 AUTH TO RETAIN AFJD9 L CACFIRIERS <br /> DOWPRFL. A. 8929841/2OB4779 B. C. D. <br /> A) NONE B) C) D) <br /> I <br /> I <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -Thi'6 io waly that"abo u-wmnd motvriary are proporiy a mired-dvee l6od.pvdkogvd,mvricd and libeled and am In proom <br /> rpndditrn io!aan;vvrtwon a�tvrdi 10 ihn a I.cobrp Bann of Intr D unvni b Tran vthn. <br /> Printe (TypedName �+ y.+� Month Day Year <br /> f <br /> f 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to feeNww dgulations for Transportation or Disposal. <br /> fj •' Printed/Typed Name Month Day Year <br /> 1} 1, <br /> FAFM <br /> T 17.Transporter I Acknowledgement of Receipt of Materials <br /> A Printedrryp d Name Slgrsa Month �jDay Year <br /> � <br /> I P <br /> I o 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name 4ignalure Month Day Year <br /> E <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I I <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 /> f GENERATOR'S COPY FORM NO.01-90291 (03/2015) <br />