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BILL OF LADING/MANIFEST 1.Shippers US EPA ID No.{If Applicable) Doxxcument No, 2.Page 1 <br /> � ;1 J Of <br /> 3.Shipper's Name and Mailing Address <br /> 4.Shipper's Phone( } <br /> 5.Transporter i Company Name 6. US EPA ID Number 4.Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number C.Facility's Phone <br /> 11.Shipping Name and Description 12.Cont iners 13. 14. <br /> Tata! Unit <br /> HM No. Type Quantity WtiVol <br /> a. <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special Handling Instruction and Additional Information y _ 614' <br /> , <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: aThis Is I fcar lesr�ot the b.Cardin a o amaterials <br /> tearial cable reporlY classii <br /> of the d Department of Tagged Onahen <br /> and]abeied and are in Proper <br /> Printed/Typed NameNMEMEMSM Hearth Day Year <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 Cisposal. <br /> Print yped Nam , <br /> _ ~ Month tray Year <br /> T <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A PgntedlTyped Name T <br /> gnature Month bay Ye <br /> P p'1 (F y� '' 1' <br /> O 18.Trarspu&T 2 Acknowledgement of Receipt Malerials <br /> R <br /> T Printed/Typed Name <br /> E Signature Month Day Year <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 Print ped Nam Signature Month Day Year <br /> DAMON <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(0312015) <br />