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BILL OF LADING/MANIFEST 1•Shippers US EPA ID No.(If Applicable) Document No. 2,page 1 <br /> 3.Shipper's Name and Mailing Address ? ' i f?�, 'k-o• t Tl C'. <br /> 883,0 W l--Tint- Rd <br /> 4.Shipper's Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporter's Phone <br /> SAF'ETY-..kl.F.EN SYSTEMS I NC 9 <br /> 7.Transporter 2 Compdn Name 8. US EPA 117�Number B.Transporters Phone <br /> C(. W�l H' TRWIR 3 U-M T RONIME N 1 /ail.. SV <br /> 9.Designated Facility Name and Site Address W') 10. US EPA ID Number C.Facility's Phone <br /> C, H��RBOR13 Of" W'11_Mk1Nf11T0N <br /> 17 r7 :€ : t" I)F:�Ml LTRE_F:T <br /> WII_Mft� G�!'ON CIA 9'Q),?4t _31 -998 <br /> 11.Shipping Name and Description 12.ConU iners 13. 14. <br /> Total Unit <br /> HM No. Type Quantity iNWol <br /> a. UN I r)I3 1 :. it)�_.,�t_. 3 (F..FI(. H NOT FXCEE_D)NG <br /> b. <br /> S <br /> H <br /> I G. <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special Handling Instruction and Additional information <br /> 24 HR E ME�GFNC,.7 41­8,00­46-8­1760 (SK TF I ) <br /> AUTH A� JBY CEN TO RETAIN LTCFh!`-:i 1) SUR ( �)���.�)�i] AS NECESSARY <br /> D07' A, 788(:,317/ 1167585 B. C. D. <br /> A) i i # C) fs) <br /> 16a.US DOT HAZARDOUS MATERIAL SHIPPER'S CERTIFICATION: mft b bow*mat the above named maiedais aro properly dessfod,6aen0ed,pemeged,mahad and Wietad mid are n pmW <br /> awkwpn fy Immocefteow6wn accordkm to me �bie mgulabDm or me DaoMm&W of Tran ion. <br /> Printed/Typ Name 0112131MI Morrih Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are n subject t federal regulations for Transportation or Disposal. <br /> • <br /> Printed/Typed Name Month Day Year • <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Print y Name Signatu Month Day Year <br /> N e r !' <br /> P J� <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> T Pri dff ame 5' nature Mpp Year <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 PrintedlTyped Name Signature Month Day Year <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(0312015) <br />