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BX) , OF LADING/MANIFEST 1.Shipper's US EPA ID No,(If Applicable) Document No. 2,page 1 <br /> CALi1a�►71�a4.587'S . g/. � of i. <br /> 3.Shippers Name and Mailing Address 18501 West Stanford Rd <br /> Attn Samuel Mrhenry <br /> TRACY CA 90377 <br /> 4.Shippers Phone( F 814--5374 <br /> 5.Transporter 1 Compan,f ;,,e 6. US EPA ID Number A.Transporters Phone <br /> SAFETY— EEN SYSTEMS INC , T•X R0@0081.2 05. 972-265-2000 <br /> 7. <br /> T ansporter om any Name ` 8. S E Nu ber B.TranspoWA <br /> ( . <br /> 9:Designated Facility Name and Site�Adti'ress SJ 10. . US EPA ID Number C.Facility's Phone <br /> CLEAN HARBORS SAN JOSE <br /> 1021 BEARYESSA ROAD <br /> SAN JOSE CA 95133 CAD059449431 O 408-441-0962 <br /> 11.Shipping Name and Description 12.Cont iners 13. 14. <br /> Total Unit. <br /> HM No. Type Quantity wwol' <br /> a. UNIVERSAL WASTE LAMPS <br /> (FLUORESCENT LAMPS) -9 CF /Z�U P <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 SH ITS## 226581269 ADc 0198 <br /> ADESA — Golden Gate <br /> 18001 Stanford Rd <br /> At.tn Lester Saba <br /> TRACY CA 95377-9708 <br /> 24H EMERG## 800-468-176 +(CH--SK—TFI) —TRANS AUTH TO RETAIN ADD' L CARRIERS <br /> A) NONE 14815/156056 P. C. D. I �� � <br /> A) NONE H)) C) D) d' "1 <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION- 'This Is to certlfy that the above-named materials are property classified,described,packaged,marked and labeled and are in proper <br /> condition for traria rtafion a—rding to the applicable regulations of the Department of Transportation. <br /> Printed/Typed Name Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject toral eg ations for Transportation or Disposal. <br /> •' Pnntedrr ed Name Month Day Year a <br /> D �V ill <br /> R 17.Transporter 1 Acknowledgement-of Receipt_of Materials <br /> A Printed/Typed Name Signature Mont Da Year <br /> �.� <br /> 'O 18.Transporter 2 Acknowledgement of.Receipt of Materials r <br /> R Printe ed Name <br /> T yp �Q� r signatUr Month Day Yea <br /> / <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L20.Facility Owner or erator.Certification of alpt'of materials covered by this form except as noted in Item 19: <br /> 1 <br /> T <br /> Y`. Printedrfyped e Signattlre th r Y <br /> WYAWWRIN <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(03/2015) <br /> i <br />