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Ask I J111111111111111i. <br />gig <br />1. Shippey s S EPA 10 No. (11 Apj <br />11c able) Document No. 2, page 1 <br />BILL OF LADING/MANIFEST <br />of - <br />3. Sh4prC,.?S Name and Mailing Address <br />4, Shipper's Phone <br />5, Trnnsporter I COMPaily Name 8.U <br />PA ID Number <br />A. Transperter`s Phone <br />7 Trinsoortei-2 Company Name S.U <br />:F1A ID Number <br />B. 7ransportoes Phone <br />S. Designated Facility Name and Site Address U <br />PA ID Number <br />C. Facility's Phone <br />11, Shipping Name and Description <br />12 Containers <br />13, <br />14.7ota1 Lh)jl <br />No. <br />Type <br />Quantity <br />w 0 <br />a_ <br />b. <br />P <br />P <br />15, Special Handling Instruction and Addiliora! Information <br />If3a, US DOT HAZARDOUS MATERIA[�S SHIPPER'S CERTIRICATION. -Ty U <br />V,:, a,;;r VA. 1,;, If 111c Ul."M-d a I,i a]!::,, <br />PrintedtTypcd NameMcIrff? <br />Doy Ya ar <br />Ub. NON-REGULATED SHIPPER'S CrUIFICATIOW i certirytlio mituriafs described abovt <br />n tfs:s roimari; not,uLjnz;1 -Disponi. <br />Prinlod/Typed Nomo r <br />AAMh Day yt,ar <br />as <br />T <br />rc <br />i7. *rr@ aspofter I AcknoMedgoment of Recolp( of Materials <br />A <br />PrtntedlTyped Name Signiatu <br />rfnnth I* <br />N <br />it <br />0 <br />16. Transporter 2Acknowledgernerit of Receipt of Materials <br />Prinl0d!Typed Name <br />Signatu15 <br />!,ftith Day yr?.qr <br />E <br />rt <br />10. Discrepancy Indication Space <br />A <br />L <br />20. Facility Owner or Operator: Codification of receipt of materials covered by this form ex <br />-4 pt as noted in Item 19. <br />I <br />T <br />PrintedlTyped Mame <br />SlignatUl <br />• Wntir Day ),Oqr <br />. .. . . . . . . . <br />......... <br />FORM No. 01•)02qi (03/2015) <br />