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BILL OF LADING/MANIFEST 1.Shipper's US EPA ID No.(If Applicable) Document No. 2.page 1 <br /> CALM 0,45875 rZLZ -o of i <br /> 3.S ' per's Name and Mailing Address DESA - G o Iden Sate <br /> 18501. West Stanford Rd <br /> Attn Samuel Mchenry <br /> TRACY CA 95377 <br /> 4.Shipper's Phone -814-5374 <br /> 5.Transporter 1 Comply"Neste 6. US EPA ID Number A.Transporter's Phone <br /> SAFETY-KLEEN SYSTEMS INC XR000013125• 972-265-2000 <br /> 7.Transporter 2 Com an Name 8. US EPA ID Number B.Transporter's Phone <br /> CLEAN H�R ORS ENVIRONMENTAL S C INC. MAD039322250 781--792-5000 <br /> 9.Designated Facility Name and Site Address TPO 10. US EPA ID Number C.Facility's Phone <br /> THERMO FLUIDS INC <br /> 12533 SE CARPENTER DR <br /> CLACKAMAS OR 97015--898 ORO000025197 503--788-4816 <br /> 11.Shipping Name and Description 12.Cont finers 13. 14. <br /> —H—M-1 Total Unit <br /> a' CRUSHED USED OIL FILTERS No. Type Quantity WWoI <br /> (NOT USDOT OR USEPA REGULATED) DM P <br /> b. <br /> S <br /> H <br /> 1 C. <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special Handling Instruction and Additional Information <br /> ADESA - Golden Gate SK SHIP* 227706705 AD201.98 <br /> 18501 Stanford Rd <br /> Attn Lester Sabo <br /> TRACY CA 95377-9708- <br /> 24H EMERG#k 800-468-1760(CH-SK-TFI)--TRANS AUTH TO RETAIN ADD' L CARRIERS <br /> DOT/PRFL A. 78733 <br /> 3 i/158033 B. C. D. <br /> A) NONE B) C) D) <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: This Is to certify that the above-named materials am properly Gassiried,desc bed,packaged,ma ked and labeled and are in proper <br /> condition for Uans rta6 accordin to thea licable re ulations of the De artment of Trans odation. <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 gulations for Transportation or Disposal. <br /> •' Printed ed Name •. <br /> Month Day Year <br /> l� •• 0G. 1 Lt- I-1 <br /> T 17.Transporter 1 A knowledgement of R eipt of Materials <br /> R ' <br /> A Printed/Typed Nam , l Signature <br /> N Y-( Month Day Year <br /> S ®L 1 <br /> P T <br /> 0 18.Transporter 2 Acknowledgement ofkneipt of Materials <br /> Ted ped Name Si na <br /> 9 Month Day Year <br /> R ., t r Y <br /> 19.Discrepancy Indication Space it <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 /> T <br /> Y Printed/Typed Name Signature Month Day. Year i <br /> 1.2 <br /> i <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(03/2015) <br />