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BILL OF LADING/MANIFEST 1 Shipper's US EPA ld No,(If Applicable) document No. J2.P1,11 <br /> of <br /> 3.Shipper's Name and Mailing Address <br /> 4.Shippers Phone{ ] <br /> 5.Transporter 1 Company Name 6, US EPA ID Number A.Transporter's Phone <br /> 7,Transporter 2 Company Name 8- US EPA ID Number 13-Transporter's 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.Containers 13. 14. <br /> Total Unit <br /> HM No- Type Quantity WtIvoi <br /> a- <br /> b. <br /> 5 <br /> H <br /> I C. <br /> P <br /> P <br /> E <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> 18a.US DOT HAZARDOUS MATERIALS SHIPPERS CERTIFICATION: This is fo ce nify that tt-aW -na mea M.H.I.mare properly dasslil described,paekaged,ma ked and labetad and are in proper <br /> wndttivn br trans It tm accordin to thea icabla uLations orrhe Pe a:tment W Trans ortaticn. <br /> Printed/Typed!Jame Month Day Year <br /> 1Gb.NON-REGULATED SHIPPE R'S CERTIFICATION: I certify the materials described above on this form are not subject to federal regulations for Transportation or Disposal. <br /> • Printed/Typed Name Month nay Year • <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> S <br /> P <br /> ❑ 1$.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed[T ed Name Signature T YP 9 Month Day Year ft <br /> E <br /> R <br /> 19-Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 2R-Facility Owner or Operator.Gertification of receipt of materials covered by this form except as noted in item 19, <br /> I <br /> T <br /> Y Pm'tod/Typed flame Signature Month Day v ar <br /> i 1111111 pill 1111111111 <br /> 11IFF-11 10 <br /> GENERATOR'S COPY FORM NO-01-90291(03/2015) <br />