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ORIGINAL -RETURN TO GENERATOR FORM NO. 01-90291 (03/2015) <br />BILL OF LADING/MANIFEST 1 Shipper's US EPA ID No. (If Applicable) Document No 12. Page 1 <br />5�1 to 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. Transporters Phone <br />INC <br />7. Transporter 2 Company Name B. US EPA ID Number <br />B. Transporters Phone <br />_ <br />FI`iV I_ PnN'1FI`ITAL. <br />9. Designated Facility Name and Site Address S; 1 10. US EPA ID Number <br />C. Facilitys Phone <br />11. Shipping Name and Description <br />12. Containers <br />13. <br />14 <br />Total <br />Unit <br />HM <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />a. <br />!N_�0_77 F N V I R0NMFNTt4L i_Y IiAZf4FZI-'F,'6 i <br />�llTASTAlCES, :SOlin N.0 S. (ME RICUR V) , <br />, <br />PR TTI, !JNI VrR AI_ WFIOT f'l AMP <br />CP <br />l DS <br />b <br />'NI VLRSAL_ Wf?STF I AMI-' <br />FLUORESCF"NT 1 -AM, -'S) <br />rJ <br />S <br />2yo <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 />;; sir+moi; �;� ��+�- +t ,►�-i r E,4} t H -L K-TFI i -i FtHNS t=ilJ I H I rl HE 101N AuU' L. f:ORk 1 Frl�i <br />(11�I •I_'I'�F^L. �• BL�i_ 'J i._ t. 725FA4B I.lr t''L_ •t .�. - 1.e <br />:'l TIF A) NnNF-. C+i n) <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION • Th's is to certify that the abo—named materials are propepropertydasairied. descnbed. oac•agod. marked and tabea,d and are m omper <br />mndton for <br />cable 1A;ii of the De nt of Tran ortationPi <br />"@"��,­�C­dnea <br />d%Typed N me Month Day yecr <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 />"'=• <br />PrintedfTyped Name Month Day <br />0 la <br />a• <br />•e <br />Yea, <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />S <br />Printed/Typed Name <br />Signature Month Day <br />a <br />Year <br />6 <br />M y t <br />P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />EPri <br />T <br />Typed Name j <br />Signature �/ /7nth Da? <br />TI <br />near <br />R <br />/ <br />r <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 receipt of materials covered by this form except as noted in Item 19. <br />T <br />Y <br />Printed/Type Nam <br />Signature i M h M <br />0 <br />�! <br />LZ_ <br />� <br />I <br />ORIGINAL -RETURN TO GENERATOR FORM NO. 01-90291 (03/2015) <br />