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k <br /> BILL OF LADING/MANIFEST 1.Shipper's US EPA ID No.(ifApplicable)-h Document No. 12 Pa e' <br /> CAl_00034687.5 of <br /> 3.Shipper's Name and Mailing Address A50 West Stanford Rd <br /> Xo <br /> Attb Samuel Mchenry <br /> TRACY CA 95377 <br /> 4.Shi/e?sone( 20j 4-1374• <br /> 5.Transporter I Company, e 6: US EPA ID Number A.Transporters Phone <br /> SAFETY— SYSTEMS INC TXR0Ia@081.2015. 972-265-2000 <br /> 7.Trac>.spart A CRr lWf ENVIRONMENTAL S C I NC.�1�1�1 X2250 B.Transporter's Phone78,—792-50001 <br /> 9.Dels..lrgttteddlFFacili Name and Site Address SJ 10. US EPA ID Number C.Facility's Phone <br /> CLEAN 14pR� BORS "SAN JOSE <br /> 1021. HERRYESSA ROAD <br /> SAN JOSE CA' 95.133 CAD0594943101 408-441-0962 <br /> 11.Shipping Name and Description 12:Cont iners 13. 14. <br /> NM No. Type Quantity WWoI <br /> a. ' 'UN3077 ENVIRONMENTALLY . HAZARDOUS <br /> X SU8STAACES, SOLID N. 0 S. (MERCURY) , CF Z-4 v P <br /> 9, PG III, UNIVERSAL- WASTLr'LAMP �S <br /> b. UNIVERSAL WASTE LAMPS �, 9 <br /> (FLUORESCENT LAMPS) 'y�S CF P <br /> s <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# _ 1 1_'.yam ADE01198 <br /> AI)ERA ' �Qfieri' ISa1 e _ <br /> 18501 Stanford Rd 03,719 v <br /> C Lester Sabo <br /> TRACY CA 95377-97087?-9-9708 � (ss`� <br /> 1)ERG#1.71 ' <br /> 24H EMERG4 800-468-1760'(CH—SK—TFI )—TRANS UTH TO RETAIN ADD' L ,AR IERS <br /> DOT/PRFL A. 8496346/1749045 B. 14815/156056 C. D. <br /> A) NONE B) NONE C) D) <br /> 168.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -rhis is to ce sty thet,tha above named materiota are properly salted,described,packaged,marked and labeled and are In proper <br /> -- wrididoeforfrens ttettoiaccordfn.td:thee stable ofthe De artmentor Transoortatim. <br /> �rintT <br /> ed/ yped Name � I/ I ' <br /> 1IpMonth D y Y <br /> 16b.NON-REG LATED SHIPPER'S CERTIFICATION: I certify the materials describ�tleboVe on flus fo�ni are nol subJ oral regulations for Transportation or Disposal. <br /> •' <br /> Printed/Typed Name • <br /> Month Day Year <br /> �• <br /> T -176 Transporter-l-Acknowledgement of Receipt of Materials <br /> T. <br /> SPrinted/Typed�Name- t ` '� �s , Signature ,o�th q y y� <br /> P W rTN C �/ (6 <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed ed Name <br /> T P c Signature ( � Month Day Year <br /> R <br /> 19.Discrepancy Indication Space �" t <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 /> T <br /> Y Printed(Typed ame. Signature Month Day Ye r <br /> > r <br /> ool <br /> ill 1 <br /> ORIGINAL,-RETURN t0 GENERATOR FORM NO.01-00291(o3/261 5) <br />