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1.Shipper's US EPA ID No (If Applicable) Document 12.Pagel <br /> B1L1 F LADING/MANIFEST S`7Z l of <br /> E <br /> '. <br /> Shippers Name and Mailing Address i 7 <br /> PP 9 � rt. <br /> r - 4: <br /> t <br /> 4.Shipper's Phone <br /> 5.Transporter 1 Company;Narrte 6. US EPA ID Number A.Transporters Phone <br /> . .,s.:.�..�Y �-i ) :i c.1,.�". ,a iti.�3S�s:��r-J�s S, thJ• . r '�-,� (+',�`„, <br /> 7.Tr�tl prte;rf.2(C8. US EPA ID Number B.Transporters Phone,ym , r r � <br /> 9.Designated Facility Name and Site Address 10. -US EPA ID Number C.Facility's Phone <br /> TO” .. _ <br /> gg <br /> 'rt rro.. ,.1 O� _.� 4 �' �� �."1 -. ,J.}�T. ,71 .i ,. {(^•a .1$arr ,`�i- � r�,�:ni�' <br /> 11.Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No. Type Quantity WWoi <br /> a. F-1 TE—r-- r tF"r T{ r I'll 15 t_pp 4t `rt <br /> k..} ) i t <br /> .i.:r y <br /> Yi t . -64 <br /> r. F r ?' <br /> b. <br /> S <br /> H <br /> c, <br /> P <br /> P <br /> E <br /> R d <br /> 15.Special Handling Instruction and Additional Information <br /> C. t tt H .•4F S r x~tT'*['t`:�.}„ <br /> < d <br /> f7t <br /> P 4th ?j! t•{.a <br /> V <br /> r. <br /> of <br /> z <br /> t e f,ti- r r.Y-f N <br /> 16a.US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION' -This is to certify that the above-named materials are pro y a led,described,packaged,marked and labeled and are in proper <br /> condition for trans ortatton'accordin to the applicable r 51 of the De P artment of Trans p ort ation. <br /> /h�Printed/T ed N me`]'1fiL <br /> P tt 2 �G!" 0,A • i I z i1 o0 Ye <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I certify the materials described above on this form are not subje t to fe I regulations for Transportation or Disposal. <br /> •' Printed/Typed Name Month Day Year • <br /> T' <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name�NE �� Signature �o th p J <br /> N h r <br /> S <br /> od 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> 7 tedfTyped Name r ` Month Day <br /> yqr <br /> /D Z <br /> E 4G <br /> R ( i� <br /> 19.Discrepancy Indication Space <br /> F <br /> A" <br /> C <br /> L20.Facility Owner or Operator:Certification of r ipt of materials covered by this form except as noted in Item 19. <br /> Ti: <br /> Y Printed/Typed ime Signature th r <br /> ORIGINAL-RETURN TO GENERATOR FORM NO.01-90291(03/2015) <br />