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BILL OF.LADINGIMAN I FEST 1 Shippers US EPA IQ No.(IfApplicahEe) oc ment No, 2•Page 1 <br /> EXEMPT i. <br /> of <br /> dressy <br /> 1250': <br /> N '35205-3145 <br /> Wilson Way GA i <br /> 3 Shippers tJame and WiNhg Ad <br /> r <br /> I YV. <br /> 0 :. <br /> 4_0610'7p on 5f�2 � 3581 <br /> t 5 Tr{attspoiter 1 Company Name 6. US EPA ID Number,? A.Transporiers Phone <br /> e.. �. <br /> SRFEI Y KtWEE l 2— 5— <br /> FT?C,FtZ�51S31:: .•.. S7 .� rf�1Z <br /> 7:Transppife�2 Consparly�t� a 6';: US EPA ID Numb6ir B.Transporters Phone <br /> It <br /> 9r Desagnated Fao llfy Name and Site Address 7 irc'4 10 '. US E:PA 0 Number C.Facility's Phone <br /> SAFETY KI::]µEN:'SYSTE15 INC <br /> 1 3 5 <br /> Hick S€�N "T t 1N1I�# A <br /> EL MiINTE ; Cf ; 51731 CAT43 �613i�3rk }-41Zs1- X616 <br /> 11:Shrpptng Name end Desctlption 12.Containers i 3. 14. <br /> Total Unit <br /> HM :, No. Type Quantity wt/vol <br /> e QN REGULATED,SOL DM � P <br /> H <br /> P <br /> P <br /> R d <br /> 15:Special Handling Instruction and Additionat Information <br /> SK SH I P# 4444 3017606 <br /> v 2`Y r 3"77 <br /> 24 HR 'EMERGENCY #i-'-800-468-1760 (SAFETY—iiL 'EN CONTRACT #94138) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEMENT CARRIERS AS NECESSARY I <br /> DOT/PRFs:. A. 25383/3565087 B. C,. 13„ <br /> A) NOME B) C) D <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION. Khf8lstocerriry1hatthe above-namedmaterials araptopedydassifled,deecihe4padegeamaeedaadiaaeen.eadare <br /> i,pmper <br /> comities for Van]ortaaea ocmrfr to thea .coder ufalierw e1 tha D8 erla}en1 of Tfene akelioh"::.b;Ge�`.�:4' .'` , <br /> I •. Printed!TypedName I,' Mortti tDay', Year. <br /> i <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described'a on this'forin ere not'subject to federal regulations for Transpoitatton or Disposal , $ <br /> •" nt ped Name ;p Mooih Day Year" • <br /> R, 17:,Transponor 1 Acknowledgement of Receipt of Materials <br /> A P i lTypped me SignaturMonth Day year <br /> O {18:Transporter 2 Acknowledgement of Receipt of Materials k <br /> R PrintedAr Name SE e <br /> T i' �Yp _ � Month Day• Year i <br /> �i 19.Discrepancy Indication Space r` <br /> 'F <br /> C <br /> t j <br /> L: 40.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19, <br /> T•` j. <br /> a� Y PrintecifTyped Name Signa - '" Month Day year <br /> � r <br /> t �3 • <br /> I ORIGINAL-RETURN TO GENERATOR FORM No.01-90291(04/11) <br /> r. <br />