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r <br />R <br />BILL OF LADING/MANIFEST <br />1. Shipper's US EPA IDNo.(If Applicable) <br />Document No. <br />2. Page <br />N <br />S <br />P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />of <br />Signature <br />9 Month Day Year <br />E <br />3. Shipper's Name and Mailing Address - It"IJ U , <br />R <br />19. Discrepancy Indication Space <br />F <br />IT)" IlICK-i (AM <br />A <br />C <br />I <br />4. Shipper's Phone ( ) 1-3 --1 , n.,r:..; <br />L <br />1 <br />20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as noted in Item 19. <br />T <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />Y <br />A. Transporter's Phone <br />Signature Month Day Year <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 EPA ID Number <br />C. Facility's Phone <br />:I -i i it fi-:i L.i it 't -ii, f I:. <br />;iyiA IN]X-T1."NDVNi'.k= 2:)nr•?KWQY SOUTH <br />TX 777571. <br />11. Shipping Name and Description <br />12. Cont <br />finers <br />13. <br />14. <br />Total <br />Unit <br />HM <br />No. <br />Type <br />Quantity <br />WWoI <br />a. <br />rliF2(f1L.v 1x71' <br />t <br />i <br />1 <br />b <br />r <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 />SK <br />I.- ii'r( i.:.i'�r.:iit l_f'•Il:`i fir:! c'.+Clli►' l+f, 1 7f-81 (�3f� <br />1f <br />n1,11'I1 Far, rac,r—.N'1 Ff:1t�v BY (-;(,:-N TO 1..J`3FF 11-3013(.ta r?�:�Fr�(:i� <br />r'��c? cv,v1„ r'f?r;s :��y <br />.;1...r11i1►1i�, r12y . <br />r�(rr�r-?r-�t•1. Fa� �����7Fti.��+ii:��ti�.�:��-� r�. �;a r�.. <br />1 <br />"Th is is to ce by that the abovo-named materials are properly classified, described, packaged, marked and labeled and are In proper <br />16a. US DOT HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: conddon for trans ortation occord,n to the applicable ro Mations of the 0e artment of Trans o utdion. <br />Printed/Typed Narne <br />be <br />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 <br />Month Day Year <br />.: <br />LE rr :. -. <br />r <br />R <br />i r. i ransponer i 1ACKnowieagement or neceipr or iviarenais <br />A <br />Printed/Typed Name <br />Signature Montt, Day Year <br />N <br />S <br />P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/T 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 />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator: Certification of receipt of materials covered by this form except as noted in Item 19. <br />T <br />Y <br />Printed/Typed Name <br />Signature Month Day Year <br />GENERATOR'S COPY FORM NO. 01-90291 (03/2015) <br />