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BILL OF LADING/MANIFEST 1.Shippers US EPA ID No.(if Applicable) Document No. 2Pagel <br /> 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.Transporters Phone <br /> 9.Desiga t Na d Site d ' L 10. US EPA ID Number C.Facility's Phone <br /> f� <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WWoI <br /> a. <br /> It. <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 /> �y <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: Tbis is to nadir,thatthe above-named material—properly classified,described,packaged,marked and handed and mein Proper <br /> condition for tantrum[ion according to mea notableregulations ohne Dernertmen 10Trans operon. <br /> Printedflyped Name <br /> Month Day Year <br /> �• <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subjectt e regulations for spo atior Disposal. <br /> e- Printed p d Ngme Month Day Year <br /> to <br /> • T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> N rinted/Typed Name Si tura Month D^'a'y(( Year <br /> F JNZWsAili <br /> 0 18.Tran iter 2 Acknowledgement of Rece' t of Materials <br /> RPrinted/T ed Name <br /> T YP Signature Month Day 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 materiais covered by this form except as noted in Item 19. <br /> I <br /> T <br /> Y Printed/Typed Name Signature Month Day /Year <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291 (03/2015 <br />