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3.Shipper's Name and Mailing Address <br /> 4.Shipper's Phone( ) <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's 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 /> i tC'1� r:i :!'9t-'..fci t i• .. -i fix <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WUVoI <br /> a. <br /> "+ii? <br /> TED <br /> b. <br /> S <br /> H <br /> I C. <br /> P <br /> P <br /> E EWR NMENTALHL-'.i_ , <br /> R d. PERMIT/SERVICCS <br /> 15.Special Handling Instruction and Additional Information <br /> •tl <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -Tris s to certify that the above-named materials are property ciassired,described,packaged,marked and labeled and are in proper <br /> Gonda—for trans ortation accordm to thea bi <br /> hoae reulahoms of the Department of Trans ortation. <br /> Printed/Typed Name Month Day Year <br /> be <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to federal regulations for Transportation or Disposal. <br /> •' Month Da Year <br /> Printed/Typed Name Y <br /> ra• <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 S r_ `� i <br /> P <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R PrintedlTyped Name Signature Month Day Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <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 /> 1 <br /> T <br /> Y Printed/Typed Name Signature Month Day Yea, <br /> ,24 HR EMERGENCY#800-468-1760 <br /> • <br /> GENERATOR'S COPY FORM NO.01-90291 (04/11) <br />