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GENERATOR'S COPY FORM NO. 01-90291 (03;2015) <br />BILL OF LADING/MANIFEST <br />1. Shipper's US EPA 3D No. (If Applicable) <br />Document No. <br />2. Page 1 <br />of <br />3. Si Name and Mailing Address D v r: d`J�,'i, :r''r' SQ P P 3 y <br />I 1 13,71,3 N Lower `•i ac 1^a,merl "k; Gt R%lr:afi <br />�„f)n..t � (.�l`� rJ.'(r''Zif'-•-ts14;�I�1f�7 <br />4. Shipper's Phone( 'irI' r`]°'�•:i - S9tair, <br />5. Transporter 1 Company Name 6. US EPA IO Number <br />A. Transporter's Phone <br />7. Transporter 2 Compan Name 8. US EPA ID Number <br />B. Transporter's Phone <br />HP <br />9. Designated Facility Name and Site Address {9 10. US EPA ICI Number <br />C. Facility's Phone <br />k.'A_ f4N (•'1f-iii'*t130RS ti.. N f...l i Li.,,l.: <br />I16,00NORTH <br />3`TH FP U'i CAD <br />IRLAWyNAIrLIT 8 4 029 U1 D,98, i 5 L ii _'7 <br />1 <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 />WWoI <br />a. <br />I `-J 0 CIEK]IS01 FJ <br />I":.�' ���� 4`.-.7 <br />i <br />"� �. 3 �.. i4 �S .,'"�tv�F [-,? r:G ,frt? <br />DM <br />1 <br />tJ <br />— <br />.ci <br />H <br />I <br />C. <br />P <br />P <br />E <br />R <br />d. <br />15. Speciat Handling instruction and Additional Information <br />wl�l <br />[[ <br />* <br />7:E <br />+H ;i <br />�#�046FRretained bt r'at or <br />a.���t�y c�{E'�1- o{ ,,:L7I <br />01) irtx.ti"aI is-an piar•'t*1 to atrld at, rlk.:bsti` u.1"? addit:iOnal t1..a-FIE,pnrteI1­ 3 On <br />gFjTi . <br />DU /P"RFL. A, 31366,37/21,78836 B. C.. �.�.. <br />F' <br />16a. US DOT HAZARDOUS MATERIALS SHIPPERS CERTIFICATION: 'this is to certify thal the above-named materials are properlycE [11rred, desc bed, packaged, marked and labeled and are in proper <br />condition for trans arlahm accardin to thea ficable re aW 5 of Lha ne arfinent of Tran, "drtalian: <br />Printed/Typed Name - j f 1 Month Day <br />Year <br />16b. NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above an this form are not subject to federal regulations for Transportation or Disposal. <br />• ' <br />Printed/Typed Name Month pay <br />Year " <br />s� - <br />T <br />R <br />17 Transporter 1 Acknowledgement of Receipt of Materials <br />N <br />P nted/Typed Name <br />Signature J ; Month Day <br />Year <br />} <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials ( ] <br />R <br />Printed/Typed Name 7i� <br />YP <br />#ure ✓T <br />Month Day <br />Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as noted in Item 19. <br />T <br />Y <br />Printed/Typed Name <br />Signature Month Day <br />Year <br />r <br />GENERATOR'S COPY FORM NO. 01-90291 (03;2015) <br />