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BILL OF LADING/MANIFEST 1,Shippers US EPA ID No pf Applicable) Occurrent Ne. 2 Page 1 <br /> of <br /> 3.Shippers Name and Mailing Morass <br /> 4.Shippers Phone <br /> 5.Transporter I Company Name 6. - EPA ID Number A.Tmntaxiars Phone <br /> 9.Treatmener2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> 9.Designated Facility No.and Site Address 10. US EPA ID Number C.FaciNys Phone <br /> 11.Saigon,Name and Description 12.ContiIn r 13. 14. <br /> Total Unit <br /> HM No. Type Ouantity WNroI <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R tl. T-F <br /> 15.Special Handling Inampction and Mtlitonal Infmnation <br /> / <br /> 15e.USOOTHA DOUSMATERIAL SHIPPER'SCERTIFICATION: 11'0 1,- °°0t'ae°read sallbasa inv 1— <br /> PrinletlRyped Name <br /> MrnIM1 Day Year <br /> 16b.NONJEODUMOSHIPPER'SCERTIFICATION: cmMy me materiels aesmead abovewmisform are nd suga[1mfWeral reg�letmsla Tmnsportavan or IFypml. <br /> PnnteGRyped Name Ni pay Year s <br /> T R 17.Treatments,,AckrgvAedm geant of Receipt of Matadi is <br /> A Pdnted?ypad Name Signature Ni Day Yea, <br /> s <br /> P <br /> 0 18,Transporter AcknowletlgemeM of Receipt of Materials <br /> TPrinted?yped Name Signorine Mwm alay Year <br /> E <br /> R <br /> 19.Discrepancy indication Spare <br /> F <br /> A <br /> C <br /> 1 <br /> L 20,Farllity Camer or Oleander:Certification of receipt of materials covered"is form except as noted In Item 19. <br /> I <br /> T <br /> y Pru eaRyped Name Signal MontM1 Oay Yam <br /> T/S/D/F COPY FORM NO.01-90291(0312015) <br />