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1.Shipper's US EPA ID No.(If Applicable) Document No., 2 Page 1 <br /> BILL OF LADING/MANIFEST of ; <br /> 3.Shipper's Name and Mailing Address i "t O <br /> 340 W Scotty Ave <br /> STOCKTON <br /> 4,Shipper's Phone( ?09r946-0637 <br /> S.Transporter 1 Company Name 6. US EPA ID Number A.Transporter'$Phone <br /> "_3 r). �,, <br /> o 2q <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B_Transporter's Phone <br /> ENV SVC INC. #ylADib:79.: 7Hf 7�3 -500 <br /> 9.Designated Facility Name and Site Address 9 10. US EPA ID Number C.Facility's Phone <br /> CLEAN HHi2BURS SAN JOSE <br /> 1021 BERRYE:SSA ROAD <br /> SAN JOSE CA 95133 CADI059494310 408--441--0962 <br /> 11,Shipping Name and Description 12.Cant iners Total Unit <br /> HM No. Type Quantity WtNol <br /> a. UN1950 AEROSOLS, (EACH NOT EXCEEDING <br /> X 1 L CAPACITY) , 2. 1, UNIVERSAL WASTE'-- Did <br /> AEROSOLS <br /> b• UNIVERSAL. WASTE LAMPS <br /> CF `5 <br /> (FLUORESCENT LAMPS) <br /> S <br /> H <br /> I C. I'IONE NON D. 13. T. REGULATED N/A <br /> P '•.]'VtRSAL- WASTE--MERCURY CC AINING <br /> E r PMENT <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> SK SHIP# 230954620 MA42790 <br /> 1)ERB#126• <br /> 24H EMER64 800--468--17&0 (_CH--SK­TF 1 ) -LATRANS AL.TH TO RETAIN ADD' L' CARRIERS <br /> DOT/PRFL A. 8008088/1518i58 8. 14815/150228 C. 800a087/151815Er D. <br /> A) NONE B) NONE. C) NONE D) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION? This is to mmly that the above-named materiais are properly ciassited,descrihad,packaged,marked and taheted and are in proper <br /> condition[or transportation accGirdim to the applicable reulation5 afthe De artment of Trans ration. <br /> Printed.ryTd Name n { Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to federal reguVations for Transportation or Disposal. <br /> Phnted(Typed Name Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A printedtTyped Name Si9 nature Month Day Year <br /> IN <br /> s <br /> In <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> RPrintedlTyped Name Signature f''r Month Day Year <br /> T <br /> v <br /> E <br /> R <br /> 19.Discrepancy indication Space <br /> t 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 Printed/Typed Name Signature Month Day Year <br /> GENERATOR'S COPY FORM NO.01-90291 (03/2015) <br /> I <br />