Laserfiche WebLink
1 <br /> BILL O� LPI�ING�MANIFEST 1 Shippers US EPA 1D No.(If Applicable) Document No. 2,Page 1 <br /> Off ; <br /> 3.Shippers Name and Mailing Address `'' ''''''v <br /> 4.Shi nE{ } f y <br /> 5.Transporter 1 Company"mi".. - 6- U5 EPA ID Number A.Transporters Phone <br /> 7.Transpb r_fd i'fp `q me'" " a. US EPA ID Number B.Transporters Phone a. '' <br /> 9. 10. US EPA ID Number C-Facility's Phone <br /> .- F ... <br /> 11.Shipping Name atrd'g,s 4ptian 12.Containers f3.' ' 14 I <br /> Total Unit <br /> HIM No. Type Quantity WtNol <br /> a. <br /> it <br /> b. <br /> , <br /> S <br /> H <br /> P <br /> P , <br /> E <br /> R I <br /> d. <br /> i <br /> 15.Special Handling Instruction and Additional Information j <br /> I <br /> i <br /> 1 Ba.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION IN,is a certify that the above-named materials are properly Gassifled,tlOSCfibad,packaged-marked and labeled and are in proper <br /> condition far vans onaGon accnrdin to the appht,able re Wations of the De ar;ment of Trans oration. <br /> PrintedlTyped Name Month Day Year <br /> t <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I cenify the materials described above on this farm are not subject to federal regulations for Transportation or Disposal. <br /> ' PtintedrFyped Name Month Day Year <br /> R17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name Signature Month Day Year # <br /> P <br /> ❑ 16.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printedff ed Name Si nature <br /> T 9 Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space o <br /> F <br /> A <br /> C <br /> L 20-Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> I f <br /> T <br /> Y Printed(Typed Name Signature Month Day Year <br /> LAkMVN-. 5 /,.'4 1:1 .1 <br /> .�t • f <br /> 3 <br /> T/S/DIF COPY FORM NO.01-90291 (0312015) <br /> i <br />