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Cwsll.IWOIfl u(.)PY IF0RMMIINO.,D1,90291(04M1) <br />BILL OF LADING/MANIFEST <br />1. Shipper's US EPA ID No. (If Applicable) <br />DocumentNo. IF.Paget <br />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 <br />A. Transporter's Phone <br />7. Transporter 2 Company Name 6. US EPA ID Number <br />B. Transporter's Phone <br />9, Designated Facility Name and Site Address 10 US EPA ID Number <br />- <br />C. Facllity's Phone <br />11 <br />A <br />11, Shipping Name and Description <br />12. Containers <br />13. <br />14. <br />Total <br />'Unit <br />[WtNol <br />F_HM__j <br />No. <br />Type <br />Quantity <br />a <br />b <br />S <br />H <br />I <br />C. <br />P <br />P <br />E <br />R <br />d <br />15. Special Handling Instruction and Additional Information <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: riasrr1.—Iffy that neaaave-namedmaterials mar properly d—Maa.daWAn d,nackaoed—ked andlaomedarwnreln"Per <br />wrwalon for Vans aon P-141m to thea ie wmiahons of IN De r rrl a1 TransaorWlon. <br />Printed/Typed Name <br />Month <br />Day <br />Year <br />16b. NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materiels described above on this form are not subject b federal reguletionsdor,Transportation or Disposal. <br />•' ' <br />_ <br />PrintedlTyped Name <br />ae <br />Month <br />Day <br />Yee, a <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name <br />Signature <br />Month <br />Day <br />Year <br />N <br />Is <br />t. <br />P <br />o <br />16. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />Printed/Typed Name <br />Signature <br />Month <br />Day <br />Yea, <br />E <br />19 Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />20. Facility Owner or Operator: Certification of recelpt of materials covered by this forth except as noted in Item 19 <br />T <br />Y <br />PrintedtTyped Name <br />Signature <br />Month <br />Day <br />Year <br />Cwsll.IWOIfl u(.)PY IF0RMMIINO.,D1,90291(04M1) <br />