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( VEOLiA <br /> ENVIRONMENTAL SERVICES <br /> 1.Generator ID Number 2.Page lof 3.Emergency Response Phone 4.Shipping�Dioc—met�Tr�cki m r Q1ySHIPPING ZyC„31 QQ <br /> DOCUMENT �, , - ;, „n c. ;,.-,+ <br /> 5.Generator's Name and Mailing AMdreSs - - Geritr tors Site liddfess(if different than mailing address) <br /> 16 4 ,.to [Mit t`i L'ti1dAi,1E <br /> Generator's Phone:-�;,.Q 4,W::*_ it i:7 <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> N J L: Ff 3 G _+ 3 1 J 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ar <br /> 8.Designated Facility Name and Site Address U.S.EPA iD Number <br /> '�.'E�1LIr�ES7EC�Fit�>tIL�AL rS,4 LUT3r:t�S. <br /> LL.C. <br /> 1125 HENSLF�S`I'REE 1 <br /> Facility's Phone; r c� x ?s't'°s RICI.1MOPJU.CA 94801 117, l 4 <br /> ga 9b.US,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> �. y 11lpSt=,fiti T( i1: ,"l T.;4 ? ii ijm lam[ ijr�i.y NOME <br /> © r�T ra tt 1 Iy:` Y t �9E _ <br /> F- •t1'�2kt��.;..!�� ..j�+� ,7t1.=�'�=,'`, <br /> LU <br /> 2'PATTER EE, DRY,SEALED.�-r_n,5. L IJJIVER',SAL�1��`rESTF <br /> 0 0 1 1 C; F 00081 F <br /> 3. <br /> 14.Special Handling Instructions and Additional information - <br /> EP:�esri.�C. t�tracter�:t'r''�'w5T`.� -�- 1'1 ERu:•1�t���:tt6� Lak <br /> r�'A:� >+119�i12 ::a':"4 12`dam <br /> -SLM1.1!41.1 <br /> 15. GENERATOR SIOFFEROR S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable intemalJonal and national governmental regulations. <br /> Ge rato'slOfferor s Prnt Wed Name igna ur on ay ear <br /> 1 <br /> 1 .Iniemational hipments Import to U.S. ❑Export from . . Port of an !ez(: <br /> z <br /> Transporter signature for exports onl : Date leaving <br /> IX 17.TransporterAckncwledgmeni of Receipt of Shipment <br /> Signature Month Day Year <br /> Transporter 1 PrintedfTyped Name <br /> 10 ? 1 1 It 1 <br /> B_ JERE LUCK -Signature <br /> TransporterMonth Day Year <br /> 2 PrintedlTyped Name <br /> 9 <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shipping Document Tracking Number. <br /> U.S.EPA ID Number <br /> 18b.Atemate Facility(of Generator) <br /> Zi <br /> U <br /> Facili 's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> z <br /> LLD 19.Report Management Method Codes(i.e.,codes for treatment,disposal,and recycling systems) <br /> d1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of shipment except as noted in Item 18a Month Day Year <br /> PrintedlTyped Name Signature <br /> GENERATOR!SHIPPER'S INITIAL COPY <br />