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BILL OFLA1ING/MANIFEST 1.Shippers US EPA ID No.(if Applicable) DocumriNo. 2.Page 1 <br /> 1of <br /> y ,. � r <br /> 3.Shipper's Name 2nd Mailing Address , 'S <br /> 4.Shippers Phone <br /> 5.Transporter 1 Company Name 8. US EPA ID Number A.Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number E.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 WtNoI <br /> l <br /> a <br /> I i)t'1T/Nt3'y '1M PIA Rl171A_.i <br /> b. <br /> S <br /> H <br /> c. <br /> P <br /> P <br /> E <br /> I <br /> i <br /> 15 Special Handling Instruction and Additional Information <br /> SK SH I r-#f 2*0 36 i;"91 r <br /> All r- E R5 NCY #61 800 468 — 1 iii R' , <br /> I .Ti—INSED, SLikt9f"QUIEINJ CARRIERS (AS s <br /> _ i if.l,l'I.. �'). l.:J I.JCyf C4�i✓J 41:�! f.`. I�..n I.)w <br /> "t <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: TNS is to wail that me aoo.e-named meteds, pvoedv uaavirea.aeeceeee,oacaa9ee,marxetl erkbaEebed and are in paper <br /> wndluon for trans orlabon accortlin to lova kaabre ulatum of the De aNnent of Trans adadon. <br /> Printed/Typed Name NOW <br /> .a a Month Day year <br /> 18b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials describetl above on this form are not subject to federal regulations for Transportation or Disposal. <br /> •' Printed/Typed Name Month Day Year a <br /> Y' r <br /> • T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A PrintedfTyped Name Signa�ure ' i- Monu, Day vre <br /> R J t, <br /> P <br /> O 18.Transporter 2 cknowledgement of Receipt f Materials <br /> R PrintedlTypad area Signature Month Day Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy In kation Space <br /> F <br /> A <br /> L 20.Facility Owner r Operator:Certification of receipt of materials covered by this form except as noted in Item 19. <br /> 1 <br /> T <br /> V Printed/Typed Name Signature Month Day ye;,, <br /> I I <br /> 24 HR EMERGENCY# <br /> GENERATOR'S COPY FORM NO.01-90291 (11/09) <br />