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GENERATOR'S COPY FORM NO. 01-90291 (03/2015) <br />BILL OF LADING/MANIFEST 1. Shipper's US EPA ID No. (If Applicable) Document NO. 2. Page 1 <br />of <br />3. Shipper's Name and Mailing Address <br />I <br />s; rr�s:;ftY•t�l`I <br />4. Shipper's Phone( ) 't` 13 i_.3 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />A. Transporter's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />B. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US FPA ID Number <br />C. Facility's Phone <br />_ <br />"A !...i ]I'•I iii 11i191 -1i1 !I i •_I l..i i- <br />t (�i� i )�I•�iar�Ys-.s:�s:�A tar:ir�.r� <br />;yF')N <br />4;416 ­4 <br />Llil 1f1?.1...�!)�1 . <br />11. Shipping Name and Description <br />12. Containers <br />13. <br />14. <br />Total <br />Unit <br />HM <br />No. <br />Type <br />Quantity <br />WWol <br />a• <br />\ <br />i,J-10, k il. i,;; ;,Lit !f .; i I L,� ;i•i! I' i.i9i _i.., 1 1» llN ii <br />I <br />t.1tEll:t�F.CtF.:;�3L. 4J(�•1!.�1'f-k"..t�F:t2f.ls�l:li...C3 <br />b <br />S <br />H <br />I <br />c. <br />P <br />P <br />E <br />R <br />d. <br />15. Special Handling Instruction and Additional Information <br />{) ( y <br />BIJ% t .1)'{ .I 6'•11 2111'-1+99 r J .]. • I ^1 . t (. r' G. l <br />it y 41 i "J :p y <br />c.?Is' 41fd F (�t1::FdCiE:lut1Y im.. no�fi �ii~,F3 1.'fClk�1 (s;1� <br />fru-rk Af ; "A(3r1.`NT-•F0IV' BY HEN TO F2ET0.111 I..)' (FN9)V-.0 ;3(11? NFE R35r- R <br />!)t)7if-�f�F�L.. ren-r�l�.`:!':ll��/1.��7•�s�Tl' iso C� 1)a <br />1 <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: -This is to cerllfy that the above-named materials are properly classilled, described, packaged• marked and labeled and are in proper <br />condition for Irans od"a,,­d,,o e applicable remilations at the Department 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 federal regulations for Transportation or Disposal. <br />• <br />Printed/Typed Name Month Day Year <br />IN - M. <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />PrintedlTyped Name <br />Signature Mordh Day Year <br />N <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />PrintedlT ed Name <br />YP <br />Signature <br />9 Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />I <br />C <br />I <br />I <br />i <br />L <br />20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as noted in Item 19. <br />lI <br />T <br />Y <br />Printed/Typed Name <br />Signature Month Day Year <br />GENERATOR'S COPY FORM NO. 01-90291 (03/2015) <br />