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2. Pfe 1 of 3. <br />a lWNT <br />filafie s#nd Mailing Addrftp $9yS 4711 Generator's Site Address (h ) <br />5�# 4987 West Ln 4587 West Ln <br />r tc; <br />Gra#or s Plxme:CA 95210 Stockton, CA <br />SlMA- <br />tansporter 1 Company, Name U.S. EPA ID Number <br />Solutions nc110924 <br />7, Transporter 2 Company Name � } � J � U.S. EPA ID Number <br />8. Designated Facility Name and Site Address 21st Century ENN, LLC: U.S. EPA ID Not" <br />5 Newlands Dr. East <br />Fernley, NV 89408 <br />Fatf Phone: 7755752760 NV . <br />HM 9b. U.S. DOT Desalption (including Proper Shipping Name, Hazard Class, l0 Number, and Paddng Group (if any)) 10. Containers 11. Total 12. Unit <br />No. Type Quantity WLNol. <br />1. Universal Waste Fluorescent Lamps I CF R <br />z <br />3. <br />4. <br />13. Special Handling instructions and Additional Information 1 . i 055 (Universal Waste Fluorescent Lamps) <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the skipping document except as noted in hem 17a <br />Pdmed/T { a e <br />V <br />,-$LC-0 (Rev. 5-11) <br />DESIGNATED FACILITY TO GENERATOR <br />14. GENERATOR11 CERTi ICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper slopping name, and are classified, pacldaged, marked and labeled and <br />3. <br />- <br />are at aA respects in propor corttA6ar fat transport according to applicable international and rtatiatal govedrwrrental regulations. <br />G s ' yped Name <br />Signature <br />Month Day Year <br />..t <br />�. <br />15. <br />❑ Import to U.S. <br />;�rt frau U S. Port of entry/exit: <br />TPorter mre <br />Date Waft U.S.: <br />cc <br />16. Transporter Admowledgment of Receipt of Materials <br />Transporter 1 Printed/typed Name <br />Signature <br />Month Day Yeaz <br />Kristopher Almanxa <br />12 <br />a <br />Transporter 2 PruteWyped Name <br />df <br />Signature <br />Month Day Year <br />17. Discrepancy <br />17a. Discrepancy Indication Space E] Quantify ❑ Type <br />❑ Residue Partial Rejection <br />❑ Full HejecN . , <br />Shipment Track.. Number. <br />17b. Alternate Facility (or Generator) <br />U.S. 9A ID Number <br />I <br />Facility's Phone: <br />17C. Signature of Aftemate Facility (or Generator) <br />Month Day Year - <br />18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the skipping document except as noted in hem 17a <br />Pdmed/T { a e <br />V <br />,-$LC-0 (Rev. 5-11) <br />DESIGNATED FACILITY TO GENERATOR <br />