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BILL OF LADING/MANIFEST 1.Shippers US EPA ID No.(If Applicable) Document No. 2. <br /> w page 1 <br /> ''AR42000039370 1 <br /> 3-Shipper's Name and Mailing Address sC on reIR I e r ran TIC, <br /> 1905 Mchenry AVE.' <br /> ESCALON CA 95320-0000 <br /> 4.Shipper's Phone{ 209-y552-6051 <br /> 5.Transporter 1 Company Name 8. US EPA ID Number A.Transporters Phone <br /> SAFETY--KLEEN SYSTEMS INC Tk R000081205 . 800--663-5840 <br /> 7.Transporter 2 Company Name 8- -f US EPA ID Number B.Transporter's Phone <br /> C�l�C C1 � 0 f�[\V r0 S.a ^[ 0.0 G <br /> 9.Designated Facility Name and Site Address �-', 10- US EPA ID Number C.Facility's Phone <br /> CLEAN HARBORS SAN JOSE <br /> 1021 RERRYESSA ROAD <br /> SAN JOSE CA 95133 CAD059494310 408-441-0962 <br /> 11.Shipping Name and Description 12.Con iners 13. 14. <br /> HNI­I Total Unit <br /> No. Type Quantity wwol <br /> a. NON D.O. T. REGULATED I <br /> UNIERSAL WASTE-MERCURY C©bTAINING <br /> EQUIPMENT CF P I <br /> . I <br /> b. UNIVERSAL WASTE LAMAS [ <br /> S <br /> (FLUORESCENT LAMPS) � CF <br /> ?may <br /> H <br /> I ° T Ul d <br /> P LIU � -1/�XtfY r►t9�• 1h A <br /> EA4 kA 0g6A*A <br /> R d- <br /> 15.Special Handling Instruction and Additional Information <br /> Z 10 4� I b5� SK SHIP'# IQ� ES12014 <br /> 24H EMERGENCY#800-468-1760-CH/SK/TF1-Contract retained by generator C�nfers <br /> agency authority <br /> On initial transporter to add or substitute additional transporters On ge e <br /> Rat or' s behalf. <br /> t <br /> DOT/PRFL A. 9213766/22 _09 B. 14815/150228 C.crU37&W/-LS539yf <br /> A) NONE B) NONE C)Nj,�.IV� <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION- 'This is to oergy thal the ebWe-MMed mater als Bre propmriy Gam1fled,deco bed,packaged,marked sod Iabr W and are In pmpe-r <br /> mndrd for tr udn accord! In IhB a icebla re 0afkne or the nment or Trana onatim. <br /> Printed/Typed Name <br /> Month nay Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I❑ertlfy the materials described above on this form are not subjectA federal regulations_Lor Transportation or Disposal. <br /> Printed)Typed Name _ <br /> Month Day Year <br /> � I <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> 11 Pr` <br /> ry e Signahare <br /> tY month Day Year <br /> S <br /> P <br /> 0 18.Transporter 2 Acknowledgemerd of Receipt of Materials <br /> T Printed/Typed Name Si oat <br /> E 9 Meath Day Year <br /> R (IC <br /> 19.Discrepancy Indication Space t <br /> F <br /> A <br /> C <br /> I <br /> L 20.Facility Owner or Operator.Certification of reoeipt of materials covered by this form excep as noted in Item 19. j <br /> I f <br /> T <br /> Y Pri ypad Nayre � Signature ,k � :uornh Day Year <br /> r,,.�ir'�,LI ` <br /> I <br /> II 1 <br /> ORIGINAL-RETURN TO GENERATOR FORM NO,01-90291(OM015} <br />