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BILL OF LADING/MANIFEST 1.Shippers US EPA ID No.(If Applicable) Document No. 2 Page 1 <br /> C:€L 300f 75509 - �.Br. � of 1 <br /> 3.Shippers Name and Mailing AddressMLJ L-No rKI-tuour 1.6. T nc. <br /> L9830 W Linne Rd <br /> TRACY CA 957304-9109 <br /> 09 <br /> 4.Shippers Phone( `-r --)836-0965 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporters Phone <br /> SAFETY—KLEEN SYSTEMS INC I TXR1210.0081205 . 972-265--2121171171 <br /> 7 Tra s rt er 2C pany ame a. US EPA ID Number S.Transporters Phone <br /> 9.Designated Facility Name and Site Address W T. 10. US EPA ID Number C.Facility's Phone <br /> CLEAN HARBORS OF WILMINGTON LL(w <br /> 1757 EAST DENNI STREET <br /> WILMINGTON CA 90744 CAD044429835 3121--835--9998 <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity wwol <br /> a. IN1`-3521 AEROSOLS, (EACH NOT EXCEEDING <br /> X 1 L CAPACITY), 2. 1, UNIVERSAL WASTE. ( M P <br /> EROSOLS <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R 7- <br /> 15 Special Handling Instruction and Additional Information 2z 3 - <br /> SK SRIF# �G- RO1 54ca9. <br /> 1>ERG#126. <br /> 2'4 HR EMEhGE:NCY #1--800-469-1760 (SK / TFT) <br /> AUTH AS "AGENT--FOR" LAY GEN TO RETAIN LICENSED SUR CARRIERS AS NECFSEiARY <br /> DOT/PRFL A. 78815317/11B7585 B. C. D. <br /> A} NC]N[: A) C1 D) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION- Md'is to mmfymatmaabn anamad matenaia are properlydasemed,dear roma.Vackaoed.maned and ianeied and are m smiler <br /> mndm�n mrma datpn acmra�n ro taea name masons mine oe deem err rrerbn. <br /> Printedrryped Name Month Day Year <br /> x x �, a 110911 <br /> B <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION:I certify the materials d—Abed above on this mare not s to ederal regulations for Transportation or Disposal. <br /> • PrintedrTyped Name Month Day Year <br /> T <br /> R 17,Transporter 1 Acknowledgement of Receipt of Materials <br /> A Pdntedrryped Name Signatu Mwrth pay Year <br /> N �— of 64 i.� <br /> P <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> T PTSignatu' _ r VaM Day Year <br /> R <br /> 19.Discrepancy Indication 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 /> T <br /> Y Pdntedrryped Name Signature Month Day Yee, <br /> 1 <br /> :IIM. .I <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(03/2015) <br />