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'1038932 <br /> 3 8 9 3 2 WORK ORDER NO. <br /> DOCUMENT NO. f! CJ` S'r"nAIGH r' IJILL OF ILADINK <br /> TRANSPORTER 1 VEHICLE ID# <br /> EPA ID !# TF,ANS. 1 PHONE <br /> TRANSPORTER 2 VEHICLE ID# <br /> EPA ID # TRANS. 2 PHONE <br /> DESIGNATED FACILITY � SHIPPER <br /> FACILITY EPA ID # SHIPPER EPA ID # <br /> ADDRESS ADDRESS <br /> CITY STATE ZIP CITY STATE ZIP <br /> CONTAINERS TOTAL UNIT <br /> NO. & SIZE TYPE HM DESCRIPTION OF MATERIALS QUANTITY WT/VOL <br /> A. <br /> B. <br /> C. --- ------------- <br /> D. <br /> E. <br /> F. <br /> G. <br /> H. <br /> SPECIAL HANDLING INSTRUCTIONS <br /> SHIPPERS CERTIFICATION: This is to certify that the above named materials are properly classified, <br /> described, packaged, marked and labeled and are in proper condition for transportation according to <br /> the applicable regulations of the Department of Transportation. <br /> PRINT SIGN DATE <br /> SHIPPER <br /> PRINT" SIGN DATE <br /> TRANSPORTERI <br /> PRINT SIGN DATE <br /> TRANSPORTER 2 <br /> PRINT SIGN DATE <br /> RECEIVED BY <br /> CHI 107 <br />