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BiLL T 1,Shipper's US EPA iD No.(If Applicable) Document No. 2,Pal <br /> OF LADENG/MANIFESe 1 <br /> C621 44- of <br /> 3.Shipper's Name and Mailing Address I_t:,t:i 7 I tl y 0(;.:a r:.R':i,t'?n <br /> 4.Shippetis Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transportees Phona <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporter's Phone <br /> 9.Designated Facility Name and Site Address a j 10. US EPA ID Number C.Facility's Phone <br /> fA-1,4114 IlflWIDWIi "i('IN ,:it-11l , 1.I,.E: <br /> fafJllD <br /> HAN IT11.tf (4) 911,1ti.,53 f.;(f))�%:.'irj�'rr::��r�i.flll !}4'}(3•..�tff f..-flit:)jit.''. <br /> 11.Shipping Name and Description 12.Contg finers T13. 14. <br /> Unit <br /> HM No. Type Quantity WWol <br /> a. ED <br /> IJN f l�!,!7:�f1l. „�. <br /> Q t f G,IC!t26�' GENT IT I_N4f.S) HECL;d <br /> b, <br /> NOV' 3 j e� 2014 1 <br /> S. <br /> N p <br /> P d' W !ti L LTHH <br /> E DEPARTMENT <br /> R d, <br /> 15.Special Handling Instruction and Additional Information <br /> UK 1's191 f :e::A-.rtrsf,flr"4 <br /> 4f3' <br /> 1It2 I:'!Y!f::ftCYt'hlf Y ,9. Et 4'9'-'�Itr(t -J 16,E (;rftf"f <br /> :i!{ t1U'f'VMF. .E (-_.'N 1 00— 6fli tiF=;1) fsllt ;.>f'11 (JENT E,()RI1ff Rf-3 (af; Nf_ !:,I:1E,!3BN_,?Y <br /> I)E]"f/PHF"I,.. A, :E481,il <br /> (3) MINI B) I:,) )�) <br /> 760.USDO7HAZARDOUSMATERIALSSHIPPER'SCERTIFICA710N: •n'''tstoW"wttheawre-namedmatedasarepropee�dass�ree.desuwod,pacYaged,markedandlabe:e6andareMproper <br /> ,gm kr ba Uon acoor to the a Ah r Jarons the Do t T <br /> Printedrryped Name EMMMMSMEM Month Day Year <br /> 16b,NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on thts tont ere of subject to federal regulations for Transportation or Disposal. <br /> r fltedfTyped ame J ! Mon Year ° <br /> 1/i'/) l<:'�_' -iii ;�. .r . <br /> Trials Transporter'1'AcknoWedgement of Receipt of Matelots <br /> R <br /> A Printe ed Name Signature ' Month a (Ygar <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials 6'0 <br /> R Printed/Typed ed Name Signature <br /> T yp Month Day Year <br /> E <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L 20,Fad li0 owner or Operator.Certification of receipt of materials covered by this form except as noted in Item 19. <br /> T <br /> Y Printedrryped Name Signature Month Day Year <br /> :It i <br /> s <br /> OENERATOR'S COPY FORM NO.01:90291(04/11) <br />