Laserfiche WebLink
BILL OF LADING/MANIFEST 1.Shipper's US EPA ID No.(If Applicable) Document No. 12.Page 8 $ of <br /> 3.Shipper's Name and Mailing Address <br /> 4.Shipper's Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporter's Phone <br /> 9.Designated Facility Name and Site Address I_.:,v7 0 10. US EPA ID Number C.Facility's Phone <br /> EVERGREEN t..'1L, Iran. <br /> ;,880 SMtITH AVE . <br /> if WARF (:A 34560 <br /> 11.Shipping Name and Description 12.Cont iners 13. 14. <br /> Total Unit <br /> _1HM­1 No. Type Quantity wtNol <br /> a. NUN—REGULATED LIQUID. NOT <br /> U :DOT REGULATED MATERIAL <br /> ( VA(_-OIL, WATER. SLUDGE ) <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> MFST R/T#1101253186 0000-370t-02 <br /> EMERGEN(-i RESP 800- 468-1760( 24 HR ) . <br /> A,, CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT C.`ARRIERS AS NECESSARY. <br /> SVDOT# A: 3233 B: <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: "rnis lam wniry lhaema awea-namae malenaca are pmoaM da..inaa,da.armed,paamem,manaa end mneme a are In P.m <br /> condition for Vansonaeon acmreln to Ine appjjtabla renalatbom of the De ravtof TieoMdon. <br /> Printed/Typed Name - Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: 1 certify the matanala described above on this form are not subjec er regal nshw Trans hon or Disposal. <br /> •' P' ted/Typed me /"M nm Day Year <br /> L a• G <br /> T17.Transporter 1 Acknowledgement eceipt f Materials <br /> R <br /> A rinted/Tcyped Name �� Sig re - Month Day Year <br /> S beQ QJE <br /> P <br /> 0 18.Transkier 2 Acknowledgement of Receipt of Materials <br /> R PdntedlTyped Name Signature Month Day Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20,Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> 1 <br /> I <br /> PmIteATyiped Name ` Signature ,4( Month Day year <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.90291(1119 <br />