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1.Shipper's US EPA ID No-(If Applicable) D cumentJ j�fo.+ 2 page 1 <br /> BILL OF LADING/MANIFEST <br /> LJ ID0 3.Shippers Name and Mailing Address ITtredi u I; t 1L. <br /> FI. Cl. 110M t,lr9 <br /> fit Gil I I i'i,)t_Ar- hij <br /> tilt I IIIV LJ4 ` ' c'Vt(_r 1(telttlNl <br /> 4.Shippoes Phone( (?i_ )i:f 0 3 'j'-1 .0 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.Transporlees Phone <br /> SYSI-EN6 IN! TY.i7��bk�tdt-?1d+[le bv`io h6'3 �'_;ESytID <br /> 7.Transporter 2 Company Name a. US EPA ID Number B.Transporter's Phone <br /> 9.Designated Facility Name and Site Address si 10. US EPA ID Number C.Facility's Phone <br /> I [_,)N NAR15UFiS aAN <br /> 1",1 13E RR VL S1:iA ROOD <br /> JOSE LA 95133 L;Al:}><5'34943 1.0 W6-441-•_+ 3-,c:- <br /> . <br /> 11_Shipping Name and Description 12.Containers 13. 14. <br /> Total Unit <br /> HM No, Type Quantity Ut1tlVol <br /> a. L1N19 jkdi AEROSOLS, (Ei4.;H NUT CXLE.L.--1].[W <br /> X 1 L L:-4ALITi V i , --. 1, UNi i:l=i<SAL WASTE— <br /> AEROSOLS <br /> b. <br /> S <br /> H <br /> I c. <br /> P <br /> P <br /> E <br /> R d. <br /> ;s <br /> 15.Special Handling Instruction and Additional Information <br /> �K :il}l ltk C, QT-1-0 71— L:,0 }tt-iti <br /> r-- <br /> i I liiilu5trial Dr � <br /> I i LitOO1c'be <br /> x:;4H Elhr Ru AU TH VC) RE i cA I N AL-WL <br /> L <br /> DG T/PRF-L A. 6517919/1765209 B. C.. D. <br /> 1=4) NUWL Bi Lri U) <br /> 163.US D07 HAZARDOUS MATERIALS SHIPPER'S CERTIFICATION: 'Th1s Is to MMfy that the above-named matenais are prapartydassRed,dascnbed,packaged,marked and labeled and a e w proper <br /> con&—for bans onauon acCofdin to tha a licab[a utaeons of the Da rtmenl of Trans orla[ron. <br /> Printed/(Typed Name If <br /> 110 Month Day Year <br /> 16b.NON-REGULATED SHIPPER'S CERTIFICATION: I cenify the male nals described above on this form are not subject to federal regulations for Transportation or Disposal- <br /> Printed/Typed Name Month Day Year - <br /> R17.Transporter 1 Acknowledgement of Receipt of f0aterials <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> T PrintediT ed Name Si nature Month Day Year <br /> T YP 9 <br /> E <br /> R . <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20.Facility Owner or Operator.Certification of receipt of materials covered by this form except as noted in Item 19. <br /> I <br /> T + <br /> Y Printed/Typed Name Signature Month Day Year <br /> GENERATOR'S COPY FORM NO.01-90291(03/2015) <br />