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1.Shipper's US EPA ID No.(If Applicable) Document No. 2.page 1 <br /> LL OF LADING/MANIFEST t',()t_. k ►�� �C�� , , .� . of 1_ <br /> r _n e <br /> 3.Shippers Name and Mailing Address te`It 1 <br /> West St al'i'I'or•'d Rd <br /> Rain aamf_€ol Mrrl"env-y <br /> TRACY C`A 9 r5,-37 7 <br /> 4.Shippers Phone <br /> 20 81.4- ._174 <br /> S.Transporter 1 Company Natrfek, 6. US EPA ID Number A.Transporters Phone <br /> 972-265--2000 <br /> SAFETY-KU= 6 SYSTEMS INC`. I-X RL7100-081•i�105 <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> 9.Designated Facility Name and Site Address F V G 10. US EPA ID Number C.Facility's Phone <br /> ` AF ETY KLEEN OF CAU-IFORNIA <br /> 6680 SMITH H AVE=., Cid- ����®�tt�eral�l <br /> NFWARK CA 9456CA CAD980887418 <br /> 12.Containers 13. 14 <br /> 11,Shipping Name and Description Total Unit <br /> No. I Type Quantity WWoI <br /> HM <br /> a. 0N RF_[3111._AlT-�f 1,,-TQIJI)) (VAC --0011-` irl T 1 <br /> l� <br /> SLUDGE) (NOT USDO T lNCIT USEl=A R?z_BI.11_vAT�HD) [7T <br /> (NOT CO REBULATE D) Q . 0 .�•� <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 /> v' Iri ftil`17.6�°�f t., .,'L� Mi�1 L��d::rv`' AI•..ir<:',Ir�i 1.r 'i <br /> ADFSA --- la=.Aden Sat <br /> 1,11501, Fit anfor d RCI <br /> tr3i• Ta 1 1=attar Saabs <br /> FRFICY CA 95377--'-_)708 <br /> =411 EMaR6* 800--4C€,8-A17FO(CIS--SIS,--T 1=i )---TRt I\N7' AU-r H TO RE:TA H'd <br /> A) NOW D C.:) I)) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: rnis ss to ce tiry Uat the above-named materiels are p ipedy dassmed,described,packaged,marked and labeled and are In proper <br /> wndlGon for Vans dation accordin to thea applicable regulations of the Department of Trans ortation. <br /> Month Day Year <br /> Printed/Typed Name <br /> lift <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to federal egulations for Transportation or Disposal. • <br /> .� Month Day Year <br /> PrintedlT ed Name� t <br /> . T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R Si ure Month Day Year <br /> A rintedRyped Name Q <br /> S ♦�1 R-4 <br /> f� sT <br /> P <br /> o 18.Transp er 2 Acknowledgement of Receipt offMaterials <br /> RPrinted(fyped Name Signature Month Day Year <br /> T <br /> E <br /> R # <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <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 Signature Month Day Year <br /> y` Prin5WTypeol Name <br /> FORM No.01-90291(03i2015' <br /> ORIGINAL-RETURN TO GENERATOR <br />