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I <br /> i Shippers US EPA ID No.(If Applicable) _ Document Np 2 Page 1 <br /> BILL OF LADING/MANIFEST7' <br /> Of <br /> 3.Shippers Name and Mailing Address I <br /> 4,Shipper's Phone( ) + <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's Phone i <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporter's Phone 1 <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 /> PP� 9 P <br /> Total Unit <br /> HM No. Type Quantity Mol <br /> a. <br /> .......J r <br /> 1 <br /> j S <br /> H <br /> i I c. <br />� P <br /> 11 P <br /> E <br /> i R d. - <br /> i <br /> i <br /> i <br /> 15.Special Handling Instruction and Additional Information <br /> e <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: 'This is to c r ily that the above-named materials are propedy classifled,Qescrlbed,packaged,marked and labeled and are in proper <br /> wnch iorr for trans ortabon accordin to th applicable iegulalonsgMe 170 ailment of Trans ortagon- <br /> PrintedfTyped Name * Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION. i certify the materials described above on this form are not subject to f4derqr9gulations for Transportation or Disposal. <br /> Printed/Typed Nam Month Day 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 /> O 18.Transporter 2 Acknowledgement of Receipt of Materia)s <br /> TPrinted/Typed Name Signature Month Pay Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C ji <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 PrintedfTyped Name Signature Month Day Year <br /> 11111111111JI111 Jill iiiii <br /> GENERATOR'S COPY FORM NO.01-90291(0312015) <br /> l <br />