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(3ENERATCR'S COPY FORM NO. 01 -OMI (04111) <br />BILL OF LADWIGNANIFEST hippart US EPA ID No. (if Applicable) <br />Document 11W 2.07901 <br />3. Shippeea Name and Mailing Addra, <br />17 20 4 <br />t -f <br />4. Shipper's Phone ENVIRQNMENTAL <br />5. Transporter 1 Company Name, 61 US EPA 10 Number <br />A. Tramipartaralr!�LTH DEPAHTMEN I <br />�90 <br />•t RNA, l—' <br />7. Transporter 2 Company Name 'Ift!) r <br />. . . . . .. . . . <br />B.Transpoftes Phone <br />9. Designated Facility Name and Sits Allorm 10, US EPA ID Number <br />LA <br />C. Facillity's Phone <br />Hj N <br />—V "A "Vtv63' -'P�UdL <br />i 0 1 1. 1-3 *1 <br />11. Shipping Nam and Description <br />12. n <br />inars <br />13. <br />14. <br />. --J. . . . I <br />Total <br />Unit <br />FHM <br />IN <br />Type <br />Quantity <br />V"01 <br />0.1 <br />.1 L5 <br />' <br />'4. W S T r., <br />It. <br />P <br />W Special Handling Instruction and Additional Information <br />fit{ 9KIP4 <br />v if, I- DI 0 r, A v It <br />A <br />�-',4 Ho EMERO'E"41.7Y <br />63K �)UTHGR]R.ED M RS'IAIN' SUSSI:.AXX-'�,"T CARFRUHRS Gig <br />DOT/ �R" L. q.1 B, <br />IJ <br />Iflo. US DOT HAZARDOUS MATERIALS sHippews critnpiwii <br />Printalliffyipad Name mwffi NY year <br />10b,N014.PZGULATEDSHIPPER'S CERTIFICATION: I Or* the MOMMIS (199(fibed SbOYS M MIS bn are net Sul;jd 1. rad.i legUW#pnv for Thirlapartaron or DjapmL <br />Primed 0 IN Monro Day Yew <br />NEW <br />T <br />R <br />1 TnmsporbK,1 Acknawledgement of Rsoeiipt of Materials <br />A <br />N <br />jPpntGdtTyped Name <br />slgryaturea0olY Yew <br />TiZ <br />W? -1 v3 <br />P0 <br />1S. Trer�r 1Ackmwledgemsfft of Receipt 5f Mateem. <br />T <br />Primetirryped Neale <br />Signature With Day Yew <br />19. Olsorepancy, Indimlon So" <br />F <br />A <br />C <br />L <br />I <br />20. Facility owner or Operator, Certification of receipt of materials covered by this form except as noted in Item 19. <br />T <br />Y <br />PdntedlTyped Name <br />Signature U0170 Day YW <br />(3ENERATCR'S COPY FORM NO. 01 -OMI (04111) <br />