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1BILL OF LADING/MANIFEST 1.Shippers US EPA IC No.[If Applicable) Document No. 2.1 1 <br /> 3,Shipper's Name and Mailing Address ❑s Re]'t 11 y # 4719 <br /> 15079 S Harlan Fid <br /> LATHROP CA 95330-9802 <br /> 4.Shipper's Phone{ 209)--234-1895 <br /> 5.Transporter 1 Company Name 6, US EPA Ib Number <br /> A.Transporter's Phone <br /> 7-Transporter 2 Company Name 8. US EPA ID Number 13-Transporter's Phone <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 791-792--•50016 <br /> 9.Designated Facility Name and Site Address ) 10. US EPA la Number C.Facllitys Phone <br /> CLEAN HARBORS SAN JOSE <br /> 1021 BERRYESSA ROAD <br /> SAES JOSE CA 95133 CAD059494310 409--441-0962 <br /> 11.Shipping Name and Description <br /> 12.Containers 13. 14. ! <br /> HM Total Unit <br /> a, No. Type Quantity WfNo! <br /> NON-REGULATED MATERIAL, (METOL BRAKE <br /> SHAVINGS) <br /> �] DF P <br /> b. <br /> S <br /> H <br /> P <br /> P <br /> E <br /> R d <br /> 724Ha'EMEE'7RG# <br /> anding Instruction and Additional information <br /> SFC SHIP# 233387275 OR 1617E <br /> 80�+-468-1760(CH--SFC--TFI )-TRANS AUTH TO RETAIN ADD' L CARRIERS <br /> DOT/PRF'L A. 7432418/646971 H. C. D. <br /> fl3 NONE B] C3 D) <br /> 16a.US DDT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION 8 f°P9` mal the above named mater ae are property claws ed,daaaibed,packaged,marked wd WAW and are n proper <br /> c°ndlk°n for rtatlan—rdi m the a hda ula6orrs o{�e oe artmenf W Tran lion- <br /> PrintedfTyped Name <br /> Aknfh Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to fed I regulations r Tran <br /> Printed/Typed Name sportation or Disposal- <br /> Montlr Day Year <br /> T 17.Transporter 1 Howled p r ' <br /> R gement of Receipt of Materials AM <br /> A <br /> N PnntedlTy a Signature <br /> Sh7or+Eh Day Year <br /> P I� 2 Z r <br /> 0 18.Transporter,2 Acknowledgement of Receipt of Materials <br /> T Printedrryped Name <br /> R not <br /> e G month oay �Year <br /> 19.Discrepancy I ication Space <br /> F <br /> A <br /> C <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 IfTyped ,,,e <br /> 1!/�+R'DfVr?1 Sig <br /> � Aknih ❑ e f� <br /> .11 1 <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291{03120 15} <br />