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1.Shippers US EPA ID No.(If Applicable) Document No. p page 1 <br /> BILL OF LADING/MANIFEST CAL000352832 81958 <br /> 3.Shippers Name and Mailing Address ar nerruc ing asslc a In <br /> 2577 W YO sell Ave <br /> MANTECA CA 95337-9641 <br /> 4.Shippers Phone( 20c—)-249-3204 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's Phone <br /> SAFETY-KLEEN SYSTEMS INC T.XR000081205 972-265-2000 <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> 9.Designated Facility Name and Site Address EVIS 10. US EPA ID Number C.Facility's Phone <br /> SAFETY-KLEEN OF CALIFORNIA <br /> 6880 SMITH AVE. <br /> NEWARK CA 94560 CAD980887418 510-795-4400 <br /> 11.Shipping Name and Description 12.Containers Tot <br /> 1 al Unit <br /> No. Type Quantity W 0 <br /> HM <br /> a. NON-REGUL.RTED LIQUID (VAC-OIL WATER <br /> SNOTGCR(REGULADOTTEDNOT USEPA REGULATILD) ' � i TT G <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> 5K SHIP# 226810804 GR15065 <br /> 24H EMERG# 800-468-1760(CH-SK-TFI)-TRANS AUTH TO RETAIN ADD' L CARRIEYS <br /> *78281958* <br /> DOT/PRFL A. 3299/156097 B. C. <br /> R) NONE B) C) D) <br /> Tills Is 1.rennybat the aeove-named materials epmceM Adamine.descrimd,P-ssl maned xoa I..,.ane are In nP.,16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: wrdmon m.b.ns ^aeon aao.d,n to lh unre able ,ulamnsonb.oeadmemmTRnsonabon. <br /> Month Day Year <br /> PrintedlTyped Name _ <br /> �• <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the matenals described above on this form are not subject to fader I g do for Transportation or Disposal •. <br /> MonthYear <br /> Printedlf ed Nam Day_ / . <br /> T 17.Transporter 1 Ackno ledgement of Receipt of Materials <br /> R SignatU Monrh Day Year <br /> A Print d/Typed am <br /> 5 \ Fir. 1 <br /> P <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials Month Day Year <br /> R Prinled/Typed Name Signature <br /> T <br /> E <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 - Siguat Month Day Year <br /> Y PrintedFryped Name <br /> :11 .I <br /> FORM NO.01-90291 (03/2015) <br /> ORIGINAL-RETURN TO GENERATOR <br />