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1'.Shippers <br /> US EPA ID No:(If Applicable) D u ent No 2 page 1 ' <br /> BILL OF`LADING/MANIFEST. ":' ..r�t of. <br /> 3.Shippers Name and Mailing Address 1 AW Weak Stanford <br /> Rd <br /> A '1 8amue.. ACI C :i7 r <br /> 4.Shipper's Phone ! .. &4'b%.374 <br /> 5.Transporter 1 Companyz Name, 6.' US SPA ID Number A.Transporter's Phone <br /> ., pp�+�m�{✓�J .,�ygp�.app,p�`A3 _ �qq� yqe�y ppq � �p�9 i8�a. <br /> ,SAi E i ♦- Uu%w. SYSTFM8 INC <br /> 7.Tr sporter 2'Compan ame 8' US EPA ID Number B.Transporters Phone <br /> VEEAW HA ORS EWV 1 ROWMVJ4TI4t. r S NC` MAD@3932225 7 a � <br /> 9.Designated Facility Name and Site AddressI iO 10, US EPA ID Number C.facility's Phone <br /> T"ERVID FLUIDS <br /> 9,2533 MW CARPENTER DR <br /> i:'LACKAMA OR '3710115- 503-788-4616 <br /> 11.Shipping Name and Description 12.ContE iners 13. 14. <br /> Total Unit <br /> HM No. Type Quantity Wt/Vol <br /> a. CRUBHEI) USED, OIL- F'II-TE RS <br /> (,NOUSDC9T fISEA ' l�l..AT ) <br /> 0 <br /> b. <br /> S. <br /> H <br /> c, <br /> P <br /> P <br /> E <br /> R d. <br /> 4 <br /> 15.Special Handling Instruction and Additional Information <br /> SK 914 28029, 4116 AD20I 9B <br /> Gtanf 0- Rd <br /> `I!`RACY:: CPQI W77 *B' <br /> 2 Ft M8&*W " 68--1.7610,(CHI. SK-TF 1) ' 'TRANS: AUTH. TO RETAIN AW L., CARRIERS <br /> ) NONE B) O) W <br /> 16a,'US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATIDN' This is to be tiry at the above-named materials are property classified,described,packaged;marked and labeled and are In proper <br /> . condiQon for Vans oda6odaccordl to the a licatile re utations of the De arlment of Trans ortation:. r. ' <br /> Printedrryped Name. Month pay Year <br /> 16b.NON-REouLATED SHIPPER'S CERTIFICATION:.I certify the materials described above on this'foml are not subject to federal regulations for Transportation or Disposal. <br /> •- Printed/Typed Name A Month Day, ,Year <br /> A Ur <br /> T #7.Transp6tter;1 Acknowledgement of Receipt of Materials r <br /> A Piird ped Name'` Signature Month Day Year <br /> d. <br /> P <br /> 0 18:Transporter 2 Acknowledgement of Receipt of Materials . <br /> R Printed/Typed Name Signature 1 Month DayYear <br /> T <br /> 'E <br /> R <br /> 19.Discrepancy Indication Space <br /> .F <br /> A <br /> C <br /> I <br /> k 20.Facility'Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> i. <br /> T <br /> Y Printed/Typed Name <br /> Sign ature Month Day." <br /> ay Year. <br /> GENERATOR'S COPY FORM NO.01-90291(0312015) <br />