Laserfiche WebLink
At .a^ <br />SILL OF LADING/MANIFEST Shipper's US EPA ID No. (If Aprcument licable) Do <br />2, Page 1 <br />3. Shipper's Name and Mailing Address <br />0 <br />4. Shipper's Phone ( ) <br />5. Transporter 1 Company Name 6. U 3 EPA ID Number <br />A. Transporter's Phone <br />7. Transporter 2 Company Name 8. U 3 EPA ID Number <br />B. Transporter's Phone <br />as <br />9. Designated Facility Name and Site Address 10. U 3 EPA ID Number <br />C. Facility's 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 />b. <br />s S <br />VEC <br />HREj�E <br />C. <br />P <br />11L <br />ZO <br />E <br />R <br />d. <br />MENTAL <br />E <br />IS <br />PARTMEN'T <br />HEAITH <br />15. Special Handling Instruction and Additional Information <br />of <br />1 <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION; "This is to certify th t the above-named materials are properly classified, described• packaged, marked <br />condition for trans rtation accordin to thea licable re Mations of the De artment of Trans �ortatinn. <br />and labeled and are in proper <br />Printed/Typed Name <br />e• <br />Month Day <br />Year <br />16b. NON-REGULATED SHIPPER'S CERTIFICATION: t I certify the materials described abov on this form are not subject to federal regulations for Transportation or Disposal. <br />Printed/Typed Name <br />Month Day <br />Year <br />Transporter 1 Acknowledgement of Receipt of Materials .3 <br />R17. <br />A <br />Printed/Typed Name - <br />Signatuie t <br />Month Day <br />Year <br />N <br />r <br />m., <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed ed Name <br />yp <br />Si natu <br />g <br />Month Day <br />Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />R C <br />I <br />L <br />I <br />20. Facility Owner or Operator: Certification of receipt of materials covered by this form ex ept as noted in Item 19. <br />T <br />Y <br />Printedriyped Name <br />Signatui 3 <br />Montt, Day <br />Year <br />® <br />GENER,V OFT „ COPY <br />FORM NO. 01-90291 (03/2015) <br />