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} <br /> � � it {rtyr tai 1��°l}r tit { #f� ;. Erx4r - . , <br /> � n,. nit} ,t�ntt�rn�ltnu�€� <br /> B( <br /> L <br /> C F LADING/MANIFEST1 . Shippers US EPA ID No (If Applicable) Document No. 2 pa e ul „ I <br /> r A' 3. Shipper's Name and Mailing Address t , E ga c i <br /> 3' lCn T2 . 4 AV <br /> - <br /> I 4. Shipper's Phone <br /> 1 , <br />( 5. Transporter 1 Company Name 6. US EPA ID Number A. Transporter's Phone <br /> 7 � <br /> ,E <br /> tr, 7 Transporter 2 Company Name 8. US EPA ID Number B. Transporter's Phone _ _ r <br /> e_ a _ ;rs , 1 . _••..IR'$ a h..1 't; SK _ !"CS1 a tl�.� �'�i - - - _,�? ,1 �q@/. #=) <br /> ii 9. Designated Facility Name and Site Address E [, 10. US EPA ID Number C. Facility's Phone <br /> 1. 021. F = F ROAD <br />} _ AIN .r iOSE ,✓A 95132 �k—Il_rIr7,1 _ , ti3 u � }L•�I1 � � —0962 <br />}? <br /> 11 . Shipping Name and Description 12. Containers 13 14. <br /> Total Unit <br /> HM No. Type Quantity WWoI <br /> a UN 9521 AE fQ _G S <br /> j <br /> T�j 7n <br /> UP� ltr. <br /> ex <br /> �r . l _ (, � :S �� � r.�u�P � � � ' , i gas <br /> um <br /> S ` J ,1 i~ , , FL 'vor t"p <br /> C. !_ s s+ h. t r- � ;a g ; II puD q�1 � ' �• �� ' <br /> b g; f i Y f !� r' � �'" T \. e �S `'� ca '�a33 IITI <br /> iD <br /> P : c r_ c ' E F ( L .f c . .. E t $ter /U I J <br /> zr <br /> { P / <br /> tl`Y E ,kms OR .a £. ! f . .._ L,.: C3 WC .?S ! -_, L .P4 � I <br /> ;y {% R <br /> y,.�( d i .lik F irk. I. ' ,s frm <br /> rr }rJ, � �L..L)r i f F . , .._P I &s <br /> e�t}} � . <br /> },t I 15. Special Handling Instruction and Additional Information <br /> ii <br /> 2;. —� r>a / �34 �31 .1v r,J— �. 7a-�17� ti�d , *,1s, i9= S . o ?'.fbPit� _ j <br /> er <br /> vrt D0 / PR ,.=tE,r-_tP2Sw y` l8'i 29 =0 B . EsEi;�' .,. ,. .? _ _ADW ... .-t . , !_•� �. ` <br /> ti It 14tx15n ':0 2 22 <br /> t - 1r1. _ rs?'aL G'iCbl'3a`. Gr ) CNE <br /> ties LJ <br /> ��41{kk4 In <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: ThIs is torpoortlythateiabove-named <br /> bove na ed matenals am Properly olasslnea aescrmed packaged marked and labeled and are in proper <br /> donator nacoo mthe applicable noel s or the oe0armom of Tvansonaion. <br /> PrintedlT a Name Monrn Day Year <br /> ill IMilo © a � I <br /> 16b. NON-RE12rULATED SHIPPER'S CEd IFICATION: I cerffy the materials described above on this form are not subject to federal regulations for Transportation or Disposal. <br /> Printf a Name ' : Month Day Year <br /> R .. 17. Transporter 1Acknowledgement ctlikeeelitt of Materials <br /> sN nnted/Typed Nam 1 Sign Month Day Year <br /> C\F � 3 � °9 <br /> P <br /> 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> Lt. 7 Yp Sign re M WM a Ye r Jl <br /> l\ c E �✓' <br /> it 119. Discrepancy Indication Space <br /> F <br /> I <br /> ti <br /> L 20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as noted in Item 19. <br /> r „ I <br /> > Y Prin[ed/Typetl ame Sign M h D y Y <br /> i; 7oi ,. <br /> r { n 'il ryr, � tt�{i- - s t � y `�xr ( § { ' s �s.y „ t �`- tt r t 1 t s z <br /> tdt }} 6 ; } t l ' lnz iia n i{If tt}l t,}gtt{cL ' ri g lU #lar` ll}w, <br /> ��jt r <br /> tt r % si ,>f 6 `.1`t�f iii fit(> .:r § 4 rr ,r ~ q crt£(i�{yr gets roti 4#. <tr t ; ' } l{tr26{ 1` L"ri('yr�ylll�R �{ Ing ;�'t: , S tu.,,�:,_;{ <br /> ORIGINAL-RETURN TO GENERATOR FORM NO. 01 -90291 (03/2015) <br />