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�0_F LADING/MANIFEST 1.Shippers US EPA ID No.(If Applicable) pDocument No. 2,Page 1 <br /> 3.Shipper's Name and Mailing Address - ____T1_o I d is n bat.IF <br /> 18501. West Stanford Rte <br /> TRACY CA `5377 <br /> 4.Shipper's Phone( j 1374 <br /> 6. <br /> 374- <br /> 5.Transporter 1 Company N`me 6. US EPA ID Number A.Transporter's Phone <br /> SAFETY—I LEEN SYSTEMS INC TX R127,10 8 i.205. 972-265-•-2''000 <br /> 7.T ansporter laany Name 8. S_EE�Q}p NAfb. ul bet B.Transpoo e®7 <br /> law"_ <br /> 9.Designated Facility Name and Site Address SJ 10. US EPA ID Number C.Facility's Phone <br /> CLEM HARBORS SAN JOSE <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE GA 95133 CIAD059494�310 4.08-4.4.1-0962 <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WI/Vol <br /> a• UNIVERSAL. WASTE LAMPS <br /> (FLUORESCENT LAMPS) �9 CF i Z�� P <br /> b. <br /> S <br /> H <br /> c. <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special Handling Instruction and Additional Information <br /> SN, t;3H f P# €2'6581,r.(=9 A1)2 019 <br /> CSI?E'SA -- Golden Bate <br /> 113501 Stan-Ford Rd <br /> C-ttri Lester Sabo <br /> TRACY CA 95377---9708 <br /> 24H EMERG 800-468--1.60(CH--SK—TI"I) —TRANS RUTH TO RETAIN ADD i._ CARRIERS <br /> DOT/PRFL A. 14815/156056 S. Cm D. <br /> A) NONE Vii) C) D) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION •This is to certify that the above-named materials are property classified,described,packaged,marked and labeled and are in proper <br /> condition for transportation accordino to the applicable regulations of the Department of Transportation. <br /> PrintedirTyped Name Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to yodkralbrilons for Transportation or Disposal. <br /> •- Printed/T ed Name Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> N Printed/Typed Name -q4A1 � Signature d Month Day Year <br /> S via <br /> P <br /> 0 18.Transporter Acknowledgement of Receipt of Materials <br /> R Prints ed Name Signature T YP 1 r � 9 ( Month Day Year <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20.Facility Owner or stator:Certificationof eipt of materials covered by this form except as noted in Item 19. <br /> I <br /> T <br /> Y Printed/Typed e Signature th0&1y <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(03/2015) <br />