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BILL OF LADING/MANIFEST 1.Shipper's US EPA la No-(If Applicable) Document No. 127age 1 <br /> -CA94ErG8- - Z I of <br /> 3.Shipper's Name and Malting Address 15RO' Reilly 5 719 <br /> Harlan Rd <br /> LATHROP CA 95330--9802 <br /> 4.Shippers Phone[ 209F234-1895 <br /> 5.Transporter 1 Company Name S- US EPA ID Number A.Transporter's Phone <br /> SAFETY— <br /> 7.Transporter 2 Com an Name 8. US EPA ID Number B.Transporters Phone <br /> CLEM 944PARS ENV SVC INC. MAD039322250 781-792-5000 <br /> 9.Designated Facility Name and Site Address SJ 16. US EPA ID plumber C.Facility's Phone <br /> CLEAN HARBORS SAN JOSE <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE CA 95133 CAD059494310 408-441-0962 <br /> 11.Shipping Name and Description 12-COME iners 13. 14, <br /> Total Unit <br /> HM No, Type Quantity WtNol <br /> a. NON--REGULATED MATERIAL, (METAL BRAKE <br /> SHAVINGS) DF P <br /> b. <br /> S <br /> H <br /> C. <br /> P <br /> P <br /> E <br /> R d . <br /> 15.Specie!Handling Instruction and Additionat tnfomtativn f <br /> 5I4 SHIP# 2333(98421 DR 16176 <br /> 24H EMERG# 800-468--1 7 613(CH--SK—TF I)—TRANS RUTH TO RETAIN ADD' L CARRIERS <br /> DOT/PRFL A. 7432418/646971 B. C. D. j <br /> A) NONE B) C? D) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: 'This ra ro osrlry that the above-named maumWsam properly Gass nae,d0upwt d,packaged,maned and labeled and are in proper <br /> w ditn far bra tion amordl ro the a (cable Watfvn0 or a De arlmentof Trans <br /> PrintedlTyped Name Month Day Year <br /> ■• ■y•.] �• <br /> 16h.NON-REGULATED SHIPPER'S CERTIFICATION: I oartlty the materials described above on this Form are not SAW toj!"regula' T portatlon or Disposal. <br /> e Printed(Typed Name Month pay Year <br /> M 2 <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A <br /> N Print y ed ame Signature Month Day Year <br /> ❑ <br /> $ <br /> P w L' <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T Pri yped Name gnature <br /> E Manch pay Year <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 q&Nryped Na a Signature - Monih Y iDay <br /> 11 .I <br /> ORIGINAL-RETURN TO GENERATOR' FORM NO.01-90291(03r2a1�} <br />