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GENERATOR'S COPY FORM NO. 01-90291 (04111) <br />BILL OF LADING/MANIFFST L 1. Shippers US - EPA 10 No. (If Applicable) Document No. 12. page 1 <br />i R of <br />3. Shipper's Name and Mailing Address�-,j J. I u r4 Tv tAe k <br />Ht t'n... Ralph <br />(,t'1 o rAd; ort CIA 9 -5 fl,` -'3 i V�"; – 1. <br />4 Shipper's Phone( <br />5. Transporter 11 Company Name 6. US EPA 10 Number <br />A. Transpor-ter's Phone <br />-,,jt�-- ylqu .-Ro w <br />c',3 h`if x, <br />i'y <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />B. Transportees Phone <br />S. Designated Facility Name and Site Address 10. US EPA IR Number <br />C. Facility's Phone <br />3, <br />... . . . . . . . . . . <br />VeIt",- 4 /1 J. <br />11. Shipping Name and DescrIpIlon <br />12. Cent <br />iners <br />3. <br />Total <br />1 4. <br />Unit <br />F—HM—I <br />No. <br />Type <br />Quantity <br />wwol <br />a - <br />A <br />4"',"k, q:1 C I'l-Y) v UVI W, <br />Wrl <br />i <br />Ar <br />V <br />I <br />b. <br />S <br />IC. <br />P <br />P <br />E <br />AUG .0 <br />201 <br />R <br />d. <br />LENI,"7 <br />IVIRON <br />AE <br />15. Special Handling Instruction and Additional Information <br />-E <br />2'4 QR t <br />13K 111--ILI-111001 ZVI"A) TO T f3sr-' (31kArE rIT <br />A <br />'j CW. <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: "Thbl&Lamibtyiha;ihcabove-namedmaterTabampropedy,otdi d kedvnaba1qdnd.np�p <br />he gWdjj._? <br />NarneUorlb Day . Year <br />Im <br />_,!5edfrypjd <br />7 p, <br />Im <br />16b. NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on lhls form aran"01 subject to iaderal regulations for Tianlportafion or Disposal. <br />Printedrryped Name Maim Day Year <br />gum <br />'f <br />R <br />I Transporter i Acknowledgement of Receipt of Materials <br />A <br />Printl(drryped Name <br />Month V�� Yon <br />A"? <br />�-�Wlwp <br />P <br />0 <br />, , <br />18, Transporter 2 Acknowredgement of Pecelpt of Materials <br />R <br />T <br />Printedfryped Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Ownei or Operator. Certification of receipt of materials covered by this form except as noted In [tern 19. <br />T <br />Y <br />Printedrryped Name <br />Signature Wool Day Year <br />GENERATOR'S COPY FORM NO. 01-90291 (04111) <br />