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FADING/MANIFEST 1.Shipper's US EPA ID No.(If Applicable) Document 2 Page 1 <br /> CAL�i003,46B7S . 13.ZV l of <br /> ,'s Name and Mailing Address HMSR — Bolden 'ate <br /> 1.8501 West Stanford Rd <br /> Attn Samuel- Mc_henry <br /> TRACY CA 95377 <br /> Shipper's Phone( 20190 14-3374 <br /> 5.Transporter 1 Company Nam€_;; 6. US EPA ID Number A.Transporter's Phone <br /> SAFETY-KLEEN SYSTEMS INC T.X R000081.205. 972-265-2000 <br /> 7.Tr nsporter 2 C an N e 8. US EPA ID Number B.Transporter's Pho <br /> TMA ��9W61 SS ENV I RONMENTAL_ .S C INC, MAD03932225�J `moi B 1-79� -5��� <br /> 9.Designated Facility Name and Site Address TPO 10, US EPA ID Number C.Facility's Phone <br /> THERMO FLUIDS INC <br /> 1.2533 SE "CARPENTER DR <br /> CLACKAMAS OR 97015--898T OR000. 0 25197 503--786-4616 <br /> 11.Shipping Name and Description 12.ContE iners 13. 14. <br /> Total Unit <br /> HM No. Type Quantity wwol <br /> a. CRUSHED USED OIL FILTERS <br /> (NOT USDOT OR USEPA REGULATED) C DM P <br /> b. <br /> S <br /> H <br /> I <br /> a <br /> P <br /> P <br /> E <br /> R d. <br /> i <br /> 15.Special Handling Instruction and Additional Information <br /> SK SH T P# 226982017 AD20198 <br /> ADESA - Golden Gate <br /> 18501 Stanford Rd <br /> Attn Lester Sadao <br /> TRACY CA 95377-9708 <br /> 241-1 EMERG# BIZ 0-468-1760(CH-SK-TF I )-TRANS AUTH TO RETAIN ADD' L CARRIERS <br /> DOT/PRFL Aa 7873331/158033 B. Ca De '>j� �t-1V G l <br /> A) NONE B) C) D) 5 . <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION 'This is to certify that the above-named materials are properly classified,described,packaged,marked and labeled and are in proper <br /> condition for transportation acconfina to the applicable regulations of the[)apartment of Transportation. <br /> Printed/Typed Name Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to federa regulati ns for Transportation or Disposal. <br /> Printed/Typed Name Month Da Year � <br /> 101 5- <br /> 90 <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed NameSignature Month Da Year <br /> N ,g Z#�4, ItP <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials. <br /> R P' ed Name Si nature <br /> T yP g t Month Day Year <br /> R 01 <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> T <br /> Y Printed/Typed Name Signature Month �Day! Year <br /> J I V It 11 3id <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(03/2015) <br /> 1 <br />