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BILL OF LADING/MANIFEST I Shipper's US EPA ID No (If Applicable) Document No2 Pagel <br /> of <br /> 3 Shippers Name and Marking Address 7—11 Mat or l a I% <br /> 2714 Stagecoach Dr <br /> STOCKTON CA 95215-0000 <br /> 4 Shipper's Phone( 209x853-1283 <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone <br /> 7 Transporter 2 Cornpan Name 8 US EPA ID Number 8 Transporter's Phone <br /> CLEAN HARX80RS ENVIRONMENTAL S C INC. MAD039322250 781-792-5000 <br /> 9 Designated Facility Name and Site Address S J 10 US EPA ID Number C Facility's Phone <br /> L'I..EAN HARBORS SAN JOSE <br /> 10?1 BERRYESSA ROAD <br /> SAN JOSE CA 95133 CAD059494310 408-441-0962 <br /> 11 Shipping Name and Description Containers 13 14 <br /> on Total Unit <br /> �tAt No Type Quantity WWol <br /> UN1950 AEROSOLS, (EACH NOT EXCEEDING <br /> X 1 L CA6AC I TY) , 2. 1, UNIVERSAL WASTE- DM F' <br /> AFROSOLS 1 (,nj0 <br /> b <br /> S <br /> H <br /> 1 C <br /> P <br /> P <br /> E <br /> R d <br /> 15 Speco,,Handling Instruction and Addd onal Information <br /> SK SH I P>t# 228817897 7110176 <br /> 1 )ERG#/126 <br /> 24H EMERG* 800-468-1760(CH-SK-TFI )-TRANS AUTH TO RETAIN AWL CARRIERS <br /> DOT/PRFL A. 8650200/1864754 B. C. D. <br /> A) NONE B) C) D) <br /> 16a US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION "'�b°"w''a'n"n'°°"rr"e"v°""r'"r'M'°r°°"*°'rw.°dowOW°am,1060'v Ad"°re.r°rr' Vf0y. <br /> I- 410—.rcord N tri. d ar i d Tia+PnntedTyped NameMonth Day Yeer <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials desrnbed ar—e ,,th s fri—are 41 sublect to federal regulations for Transportation or Disposal <br /> • <br /> Printed/Typed Name Month Day Year a <br /> se <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> s Al. )I,A -71 111 <br /> P <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> RPnntedlT ed Name S nature <br /> T YP ig Month Day Year <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20 Facility Owner or Operator Certif"lion of receipt of materials covered by this form except as noted in Item 19 <br /> 1 <br /> T <br /> Y Pnnted7yped Name Signature Month Day Year <br /> GENERATOR'S COPY FORM NO 01-90291 (0372015) <br />