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ORIGINAL -RETURN TO GENERATOR FORM NO. 01-90291(03/2015) <br />BILL OF LADING/MANIFEST !nt No., <br />12. P, <br />of <br />3. Shipper's Name and Mailing Address <br />4, Shipper's Phone <br />5. Transporter 1 Company Name 6US EPA ID Number <br />A. Transporter's Phone <br />7. Transporter 2 Company Name & US EPA ID Number <br />8. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />C. Fadlity's Phone <br />11. Shipping Name and Description <br />12. Containers <br />13. <br />14: <br />7otal <br />Unit <br />j P0 IF I <br />15. Special Handling Instruction and Additional Information <br />16 a - US DOT HAZARDOUS MATERIALS SH I PPER'S CERTIF I CAT ION � corid! lion for transportation ae ordinq tothe <br />of irransp ortation <br />PrintedfTyped Nam <br />Mon <br />,!h Day Year <br />16b. N -ON -REGULATED SHIPPER'S CERTIFICATl I certify the materials described above on this form are not Viec'No fed�ral regulations for Transportatior or Disposal. <br />viel <br />T <br />17. Transportar 1 Acknowledgement of Receipt of Materials <br />A <br />�ll ted/TypedQ <br />Signature <br />L�� <br />Moath <br />s <br />i 1 10 <br />I <br />0 <br />18. Tral 2 Acknowledgement of Receipt of Materials <br />R <br />Signature,, -1 <br />Month Day Year <br />R <br />15;1 <br />19. Discrepancy Indication Space <br />L <br />20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as rioted in Itern 19. <br />ORIGINAL -RETURN TO GENERATOR FORM NO. 01-90291(03/2015) <br />