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77 <br /> BII_ OF �AD'ING�MANIFEST i .F 1.Shipper's US EPA 1D No.(if Applicable) Document No. 2.Page 1 <br /> � of <br /> s3. - <br /> t 3.Shippers Name and Mailing Address <br /> x <br /> 4.Shipper's Phone( ) <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporters Phone <br /> 7.Transporter 2 Company Name S. US EPA ID Number B.Transporters Phone <br /> i <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number C.Facility's Phone <br /> f <br /> 11.Shipping Name and Description 12.Containers 13, 14. <br /> Total Unit <br /> #„ HM No. Type Quantity WWot <br /> J b. <br /> S ] <br /> H <br /> I C. <br /> P <br /> P <br /> r.. <br /> E <br /> R I d. <br /> � i <br /> 15.Special Handling Instruction and Additonal Information <br /> , fII L <br /> 1 • �. v. ! f. s. - l�ri, v 'l�'�^.,:'Y Sr �S ((,, <br /> f <br /> A - <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -This is to Certify that the above-nan d materials are property dassified,described packaged,ma ked and labeled and are in proper <br /> condition for transportation amordirg to thea licaaa re ula"ns of She Pe artment of Trans ortation. <br /> Printed/Typed Name Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this Form are not subject to federal regulations for Transportation or Disposal. <br /> Printed/Typed Name Month Day Year <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name Signature _ w Month Day Year A <br /> P <br /> D 18.Transporter 2 Acknowledgement of Receipt of Materials' <br /> R Printed/Typed Name Signature Month Day Year <br /> x F <br /> R <br /> t 19.Discrepancy Indication Space <br /> F � <br /> A <br /> i C <br /> 1 I <br /> L 20-Faciiity Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> t � <br /> Printedryped Name Signature Meath Day Year <br /> IMMEMM <br /> - <br /> t' ": ''- = FORM NO.90291(11196) <br />