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BILL OF LADING/MANIFEST 1.Shipper's US EPA ID No.(If Applicable) Document No, 2 P e/ <br /> ( b q 03 fl <br /> 3.Shipper's Name and Mailing Address <br /> 4.Shipper's Phone{ ) <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporters Phone <br /> .. . . . <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> IN Ft � <br /> 9.Designated Facil'€ty Name and Site Address 10. US EPA€❑Number C.Facility's Phone <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WtIvol <br /> a. <br /> _. . .. �ER, PC 1"6q <br /> O©.®.yd <br /> b. <br /> S <br /> H <br /> E 10.0 1 rJV 0o0.4.0 <br /> R d. <br /> 15.Special Handling Instruction and Additional Information <br /> 4Ff E}+iERG# ti t 'i :. ;t=.. l - ,K - Fi ? -Tf AI~4:i ANTE..! Tiic;+4 AJlTjr' L. CARP�1 r. <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION' "This is to rertiry that the above-named materials are properly dassifie describe ,packaged.marked and labeled and are m proper <br /> mrediPon Fnr Erans odalbn accortlin to the a licahie re-1arione o a De a ent of Tram ortatinn. <br /> PrintedfT ed Name �],[� Month Day Year <br /> YP J <br /> A/ <br /> KA/`i ��1 rr 11 r r, O C3 U <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 /> Prinied/Typed Name Month Day Year � <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A intedlTyped Name,, ignatute Month Day Year <br /> 5 � ►`'�Ci v I� Z0 <br /> P <br /> 0 18.Transporter 2 Acknowledgement of Recei t of Materials <br /> R Prin yped ame Signature —� Month Day Year <br /> E ��_ G' 07 -7.0 <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L20.Facility Owner or Operator:Certification of receipt of materials covered by this form except as noted in Item 19 <br /> I . <br /> T <br /> Y PrintedlTyped ame Month Day Year <br /> r <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291 (0312015) <br />