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I <br /> Shipper's US EPA ID No.(If Applicable) Document No. 2,page S <br /> BILL OF LADING/MANIFEST pe 12�0Cn '•::E;i�i - �- �,�. ar <br /> 3.Shippers Name and Mailing Add ss e 5 3 f' <br /> :3 10.,., Miner Ave., LA 93205--4713 <br /> stu <br /> 4.Shippers Phone{ } <br /> 5.Transporter 1 Company Name 6. US EPA iD Number A.Transporter's Phone <br /> SAFETY—K1..EEN SYSTEMS I tib:: <br /> T X R0000� 8a1-�� <br /> US EPA Ny- S.Transporte�rs P�ha-nTr D5�FNYIRONWNTAL S rI� . e <br /> 7. e <br /> 9.Designated Facility Name and Site Address Fly.. 10. US EPA ID Number C.Facility's Phone <br /> CLEAN'HARBOR?y OF BUYTONW11_i,..OW <br /> P-500 !..OKF-RN ROAD <br /> BUT TCTN rtEI� t_0W CA 93206 C AD98067S275 <br /> h <br /> 11.Shipping Name and Description 12.Cont finers of 1 Unit Total Unit <br /> Nc. Type Quantity wtlVol <br /> HM <br /> N/A NON UOT REG1J1_A_rVD MATERIAL, M r <br /> (GCD&TAINS UREA) , N/A r <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 /> "7 F'(t .fir 1D <br /> 9 <br /> J. r <br /> ='4H FMfr;RS g00_4�H--?'760iCH—SK--TF1 3—TRANS pLl H TO RETAIN FlUU* I CARRIERS <br /> })(3,f/PRFL A. $470765/1728262 8, C. D. <br /> A) NONE B) C) D) <br /> PDHAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: 7hie ie to wrhfp that lne eeoru-named metvnats a re propvay dass,trad.dencr Wd,oarkapvd,raefked and tdUerod and are in proper <br /> .onaldwlwr"i�Wal�nnn nr 1he Do Mrn,nt d Trhnn Dilation d <br /> ped Name month Day Year <br /> GULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not&ubject to federal regulations for Trangportatlon or Disposal. <br /> ' ped Name Month Day Year <br /> •- <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A nntedlFyped Nam Signature I Month Day Year <br /> N <br /> P <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R PrintedlTyped Name Signature month Day Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20.Facility Ownar or Operator CArtification of receipt of materials covered by this form except as noted in Item 19. <br /> I <br /> T <br /> Y PrintedlTyped Name Signature Mon[h Day Year <br /> r_rntGraeTnR C (,C)9V FORM NO,01-91)291[1731201 <br />