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o ,Peers Name and Mailing Address KU L Ab r' � - <br /> 881-40 W t.R���er RCI Y nt�. <br /> TRACY CA 95304-91 19 <br /> 4.Shipper's Phone( ���t��-B,-iEi—f?1��5 <br /> 5.Transporter 1 Company Name <br /> 6. US EPA ID Number <br /> �f- 1' <br /> --KL-['-.EN E ,y 'T_'h I NL A.Transporter's Phone <br /> 7.Transporter 2 Compan Name 1 I s 12-265-awl r—. _ <br /> c—. <br /> CLEAN HAR +ORS ENV SVC t3. US EPA ID Number D.Transporter's Phone <br /> INC, MAD039,'i:'?c 50 IE'1-7c►� =1Z1tAfZt <br /> 9.Desigrtaled Facility Name and Site Address 10. US EPA ID Number C.Facility's Phone <br /> CL FaN HARBORS SAN JOSE <br /> �'� <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE CA 95133 CAD0594,94310 <br /> >•��2>-441�-Q�9(ar <br /> 11.Shipping Name and Description <br /> HM 12.Containers 13. 14. <br /> a. Total Unit <br /> ON 19`50 AEROSOLS, (EACH NOT EXCt_EL).rN(� No. Type Quantity VvUVoI <br /> X 1 L CA�ACITY) , 2, 1, UNIVERSAL WASTE-- <br /> AEROSOLS Dt=t P <br /> b. 71 <br /> S <br /> H <br /> P <br /> P <br /> E <br /> R J. <br /> 15.Special Handling Instruction and Additional Information <br /> 1 )E.RG#i,'�I- SK SHIP# 2295S419F 8015429 <br /> 24H EMERBA 800-468-1760 (CH-SK-TF I) -TRANS RUTH 'To RETAIN ADD' L CARRIERS <br /> DO-T/PR[=L A. 788631711187585 B. C. D. <br /> A) NONE A) C) D) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: 'This is to certify that the above-named materals are property classified,described,packaged,marked and labeled and are In proper <br /> condition for TranMor�taunacc,,din e appi,cable re ulalions of the Department of Trans ortauon. <br /> Printed/Typed Name <br /> r Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are net s;u ecl to federal regulations for Transportation or Disposal. <br /> Printed/Typed Name <br /> Month Day Year <br /> BEE <br /> �• <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> — — <br /> A --Pri d/-i'yped Name Signature rr <br /> Month N - ) /' /� ,✓'1 =�) Day Year <br /> .(. + <br /> 0 1 ranspotter 2 Acknowledgement of Receipt of Materials _- <br /> R Printed/T'yped Name Signature <br /> E <br /> o_ Month 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 /> 1 <br /> T <br /> y PrinledfTyped Name Signature Month Day Year <br /> 1I#800-468-1760 <br /> GENERATOR'S COPY FORM NO.01-90291 (0312015) <br />