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BILL OF LADING/MANIFEST 1.Shipper's US EPA ID I (If Applicable) oc nt o. 2page1 <br /> ' of <br /> 3.Shipper's Name and Mailing Address Gardner T7'uckiT19/Cciis;ic Sales IP <br /> 2577 W Yosemite Ave <br /> MANTECA CA 95337-9641 <br /> 4.Shipper's Phone( 209)-249-3204 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number <br /> A.Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Numberl <br /> B.Transporter's Phone <br /> 9.Designatetl Facility Name antl Site AdtlressEVG 10. US EPA ID Number C.Facility's Phone <br /> SAFETY—KLEEN OF CALIFORNIA <br /> 6880 SMITH AVE. <br /> NEWARK CA 94560 CAD980.887418 510-795-4400 <br /> 11.Shipping Name and Description <br /> 12.Con iners 13. 14. <br /> HM Total Unit <br /> a. NON—REGULATED LIQUID (VAC—OIL WATER No. Type Quantity wtfvoi <br /> SLUDGE) (NOT USDOT/NOT USEPA RMULATILD) <br /> (NOT CA REGULATED) TT G <br /> b. <br /> S <br /> H <br /> 1 c. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special truc0on and Additional Information <br /> $13%141^10 <br /> // <br /> SK SHLP# A15065 l'rw <br /> 24H EMERG# 800-468-1760(CH-5K—TFI ) —TRANS AU RE-AIN ADD* L CARRIERS <br /> i <br /> DOT/PRFL A. 3299/156097 B. C. D. <br /> A) NONE B) C) D) <br /> 16a.USDOTHAZARDOUS MATERIALS SHIPPER'SCERTIFICATION: �M1i31m°Blab'"'a'he a roi°°�u�o°ar a°:em°e,aeca;ma.om a,r°°nrm a�a°e°iea a, aremrmrer <br /> Pnnted/Typed Name mmsa uwcb waom alba o° wrrairea eoapn. <br /> Month Day Year <br /> I Sb.NON-REGULATED SHIPPER'S CERTIFICATION: I MI*Me materials described above on this form are not gubiectto federal regulations for Transportation a Disposal. <br /> Printedfryped Name <br /> ���� DeY Year <br /> R17.Transporter 1 Acknowledgementof RecalpWLIVIaterials <br /> A Pnn Nome Signature <br /> g Month Day Ye <br /> P <br /> 0 18.Trans o er 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name _. <br /> Signature <br /> E M M Day Year <br /> R <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 /> I <br /> T <br /> Y tedlTyped Name Si lure <br /> Monffil Day Y <br /> 11 <br /> ORIGINAL-RETURN TO GENERATOR FORM No.01-90291(03/2015) <br />