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S <br /> f <br /> BILL.OF LADING/MANIFEST 1.Shipper's US EPA ID No.(if Applicable) Document No. 2 Page 1 <br /> of <br /> 3.Shipper's Name and Mailing Address <br /> 4.Shipper's Phone{ ) <br /> S.Transporter 1 Company Name 6. US EPA 1D Number A.Transporters Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporter's Phone <br /> 9.Desi a t Na nd Site tii I,& 10. US EPA ID Number C.Facility's Phone <br /> AIJ 711 q1400 <br /> 11.Shipping Name and Oescripton 12.Containers 13, 14. <br /> Total Unit <br /> HM No. Type Quantity WtNo <br /> a hiC1N RFiytJL_iJl'€ I t. 1i l D (VAC -(J [L WnTUR <br /> Si_ U ICF) fiyiOT USI7O /NO L!Bi Ri�:SLILAJ <br /> (NOT CA RFGUI ATED) � t4fj <br /> J <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information , 'T <br /> SF: S,[AIP4 <br /> t=Pr1ERGENJJ h -'t 1�1— G - ?Gid t; j <br /> ri!_I "H J "eACFNT—FOR " JBY GEN TCI RETAIN LI'CFNSF0 SUB CARRT.VJ AS NIFC-FSSAR <br /> Tr!`ITf�"er{Fi �? ��`'`=;r-!Il �tF.�G'_!"_) .r r.•. I"ju <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION "This is to certify that the above-named materials ars properly dassiped,descrihed,packaged,marked and labeled and are in proper <br /> ocindition for trans ton aooading to the applicable rei of the 13aparimAni or Trans oeabon- <br /> PrintedlTyped Name Month Day Year <br /> 16b•NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject t I regulallons fo Wsi or Disposai- <br /> Printed p d Name ! Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A rinted/Typed Name Si Lure Month Day Year <br /> N kill,'` � �jo L+ <br /> S <br /> P <br /> 0 18.Tran iter 2 Acknowledgement of Rece' t of Materials <br /> R PrintedtT ped Name Signature T y fd Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19" <br /> I <br /> T <br /> Y Printe111Typed Name t Ss9nature Monro Day Year <br /> 11 .� !111 Jill pil 111 111JI iiiiii �iiji� <br /> ORIGINAL—RETURN TO GENERATOR FORM NO.01-90291 {031 <br />