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VEOLIA <br /> ENVIRONMENTAL SERVICES <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shippinngg Document Number 98835$ <br /> SHIPPING _= 1_ LZ i.J 8 3 5...._ <br /> DOCUMENT is i k Il ii c i7,r=,it fi§R7 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> c;��af�nc.ci. <br /> 4545;:_PJ4 TAS L441: SAME <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> '#9 .€ °tea 5.) 1) <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name _ <br /> °`x:='' C. #-1 T �1 it f, <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> � <br /> Facility's Phone: <br /> 1J y.F ob�ty <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Codes <br /> HM and Packing Group('d any)) No. Type Quantity Wt-Nal. <br /> 1 t�5i':Myy��Ayqyk.�.�.J"�'#ii;'�'� 3,.€I.',�r <br /> r by <br /> z 2. <br /> w <br /> D <br /> 3. fi) <br /> D <br /> I <br /> 4. <br /> l <br /> i <br /> 14.Special Hanching Instructions and Additional Information <br /> r <br /> 15. GENERATOR SIOFFEROR 5 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generalor'"slDfteror's PdntedlTyped erne igna ure / on ay Year <br /> ..7�.�'+M�,�'f (�f 9'�J� � �e.J•�'. ,!, / 16 C.7'r <br /> w 16.International Shipments ❑Export from U.S. Port of entrylexit: <br /> F 1:1 Import to U.S. <br /> z <br /> Transporter signature(for exports onl Date leaving U.S.: <br /> 17.Transporter Acknowledgmen of Receipt of Shipment <br /> a onth ay Year <br /> T rterI Printedffyp Na e <br /> rgR 'r r M <br /> 0. <br /> Month Day Year <br /> aTransporter 2 Printeeyped Name Signature <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Rhinnint cument Tracking Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> t <br /> LL Facilit s Rhone: Month Day Year <br /> W 18c.Signature of Altemate Facility(or Generator} <br /> 4 <br /> 2 <br /> C- 19.Report Management Method Codes{i.e.,codes for treatment,disposal,and recycling systems) <br /> 0 1 2. <br /> 3 4. <br /> 20.Designated Facility Owner orOperator.Certification of receipt of shipment except as noted in Item laa <br /> PrintedlTyped Name Signature Month Day Year <br /> GENERATOR 1 SHIPPER'S INITIAL COPY <br />