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ILL OF LADING/MANIFEST 1.Shippers US EPA ID No.(If Applicable) pcument T. 12.page 1 <br /> - "Z 2� I! of <br /> S.Shippers Name and Mailing AddressIEq. t <br /> j 9 <br /> 5 <br /> rt . <br /> fit,I;r 43 Ivj! I. t'�t.:4rE:-ruf-y E`f' 7 <br /> I R\f,r` <br /> 4.Shipper's Phone <br /> 5.Transporter 1 Company'N rna 6. US EPA ID Number A.Transporter's Phone <br /> o _ e. <br /> ,v -.... _ <br /> 7.Transporter 2 Company Name 8. US EPA ID Number B.Transporters Phone <br /> E_.I`t + E °�'# t `r tilt d lit�tl I!'T P... fes• �T no--i -:..r c. eta ,AI 7":'r_ s�tl�0 <br /> 9.Designated Facility Name and Site Address TP0 10. US EPA ID Number C.Facility's Phone <br /> SE <br /> izff;rP� I:1_'r-irl—a:y^t p <br /> GLI`ICf',s`)MAS OP 9•7171 V--- V-M8 01M0f11,'7!R51 97 <br /> 11.Shipping Name and Description 12.Cont finers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WI/Vol <br /> a, <br /> (NOT W7100177 nR USF-PA RF rE L.ATr eT_)) of <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 /> I 6§ q <br /> fZ 3"_? F ^-'k�i 1 F €f ,C.g <br /> ) <br /> P=u t E I AS `f t_I f.l'T---C-Q-IRr, My' t'-rC`N TE) REETAIN LICENSED .)Lffl IPAR IE `"z f7`8-' CHID-=(_-1—C11-R )1= <br /> e% 78_T n s.'; C;f P? }.' 23, I.'fl Fi� <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION Thcois Is to rs kfy that the above-named materials are properly dassir lhd described,packaged,marked and labeled and are in proper <br /> • ndition for Vans station accordin to the a licable re ulations of the De artment of Transportation. <br /> Printed/Typed Name Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subject to fede regulations for Transportation or Disposal. <br /> • Printed/Typed Name Mont y Year •. <br /> wk. Pat <br /> Ub t+ <br /> T 17.Transporter 1 Ac nowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed Na\�meMon„I Signature j) ' ga7y �Y <br /> N <br /> S <br /> P <br /> o 18.Transporter 2 Ackndgement of Receipt of Materials <br /> R Printed/Typed Signature _ Month Day Y <br /> E (rte 1 <br /> R — <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <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 Year <br /> Z.I <br /> # 7 <br /> Tr <br /> FORM N0.01-90291(03/2015) <br /> ORIGINAL-RETURN TO GENERATOR <br /> i <br />