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BILL OF LADING/MANIFEST 1.SNppers 1111 ID No (If Applicable) Document No 2.mge1 <br /> s a asr. <br /> 3.Shipper's Name and MailmD A6cress Ba 5 a I It P. <br /> 11888 W Linne Rd <br /> TRACY CA 95377-8102 <br /> 4.Shippera Phone( 209Y833-3670 <br /> S.Transporter 1 Company Name 6. US EPA ID Number A.Transporters Phone <br /> qaFFTY—Hipplid —' <br /> T.Tmnspolar2 Compary Name 8. US EPA ID Number B.Transpovers Phone <br /> CLEAN HARBORS ENVIRONMENTAL S C INC. MAD039322250 781-792-5000 <br /> 9.Designated Facility Name and Site Address Si 10. US EPA ID Number C.Feciliiy's Phone <br /> CLEAN HARBORS SAN JOSE <br /> 1021. BERRYESSA ROAD <br /> SAN JOSE CA 95133 CAD059494310 408-441-0962 <br /> 11.Shipp,Name antl Description 12.Can mars 13. 14. <br /> Tolal Unit <br /> HM No. Type Quantity WWoI <br /> a. UNIVERSAL WASTE LAMPS <br /> NOT USDOT REGULATED •BP P <br /> (METAL HALIDE LAMPS) Op.( RR 0065,0 <br /> b. UNIVERSAL WASTE - LAMPS <br /> NOT USDOT REGULATED CF P <br /> s oo a oo e.yp <br /> N <br /> 1 c <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special H.Wiing Instrudbn and Additional Irdarmatlon <br /> SK SHIP# 228759882 BA20686 <br /> 24H EMERG# 800-468-1760(CH-SK-TFI)-TRANS .RUTH TO RETAIN ADD1L. CARRIERS <br /> DOT/PRFL A. 12821/150236 B. 11130/150228 C. D. <br /> A) M003 B) M003 C) D) <br /> 16a.U5 DOT HAZARDOUS MATERIAUS SHIPPER'S CERTIFICATION: w `eyvin't erea. p°„°'„ynauew b.'.° e� �a��m'°aenin pop« <br /> PrintetlRyped Name w,,a oay veer <br /> I6b.NON43EGUUATEDSHIPPER'SCERTIFICATION: lc Mtl Mematedaseeambeeabwon Misf arenot q or plgwaal. <br /> nlao➢ yped Name Mmm oay year <br /> T 17.Trareporier 1 A moa4edgement of Receipt of Materials <br /> R <br /> A MtlRypetl Na aaWre Mmm oay Year <br /> O16.Trareporter 2 Ad no vedgerrent of Receipt of Melanins <br /> 7 PnnteNTyood Name Signature AbnM Day Yea• <br /> E <br /> R <br /> 19.Discrepanry Indicadon Space <br /> F <br /> A <br /> C <br /> U 20.Fadlity Owner or Operator:Gernflise0on of recelpt of materials cnvaed"is except as noted in Item 19. <br /> Y PnntedRyped Name Signature Mmm pay year <br /> 24 HR EMERGENCY#800-468-1760 <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(032015) <br />