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hipper's US EPA ID No.(If Applicable) Document No. 2.Page 1 <br /> BILL OF LADING/MANIFEST of <br /> 3.Shippers Name and Mailing Address <br /> 4.Shippers Phone( - ) <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporters Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.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 Total Unit <br /> HM No. Type Quantity WWol <br /> a. <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special Handling Instruction and Additional Information <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: Intense m eemp that he shrove-named materiels are pmpady denoted.desedem,papraced,marred and labelad and are in proper <br /> mmieon for earemortemon arcomind to Me applicabler uedons of the determinant or Transetelion. <br /> Pnntedfryped Name Month Day Year <br /> ea <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I earthy the materials described above on this form are not subject to federal regulations for Transportation or Disposal. <br /> •- Printed/Typed Name Month Day Year a <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> O 18.Transporter 2-Acknowledgement of Receipt of Matenals <br /> R Printedrryped Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L 20.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19. _ <br /> 1 <br /> T <br /> y Printed/Typed Name Signature Month Day ar <br /> GENERATOR'S COPY FORM NC 0291(11/09) <br />