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$NIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> pOGUMENT LCA 0388 581 8275772669 <br /> 5,Gewatoe.Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> Petco #1319 Petco#1319 <br /> 2094787726 5406 Pacific Avenue 5406 Pacific Avenue <br /> eeneratora Phone: 209478 Stockton CA 95207 Stockton CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name9,0w �� ,r�yr U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address P-1st Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Faci' sPhone: 7755752760 NVD98121895338 <br /> ga 10.Containers 11.Total 12.Unit <br /> HM gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group('rf any)) No. Type Quantity wtNol. <br /> a <br /> 1-Non—Regulated EWaste (Electronic Devices), 1 DF 00076 P <br /> O <br /> 4 <br /> a <br /> W <br /> 2Non -Regulated EWaste (Electronic Devices), 5 CF 00013 P <br /> 3.Universal Waste — Lamps (Fluorescent Light 1 CF 00017 P <br /> Tubes), <br /> 4. <br /> 13.Special Handling Instructions and Additional Information 1. 103579(E l ect r°o n i c Waste) 2. 103579(E 1 e ct r ort i c Waste) 3. <br /> 103585(Fluorescent Light Tube,, Whole (Universal Waste) ) <br /> 14.GENERATORS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately dew by the proper and are classified,packaged,marked and labeled/placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national goverrmrerutal regu <br /> tor's/Oiferoes Printed/Typed Name Si 0 Petco Month Day Year <br /> FT141W� I V 1 101 16 P018 <br /> -j 15.International Shipments Export from U.S. Port (exit <br /> F- ❑Import to U.S. ❑ <br /> ? <br /> Transporter Si tore for rts only): D .S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials j <br /> Transporter 1 Printedfryped Name Signature Month Day Year <br /> O <br /> CL <br /> y Anthony Mack <br /> z Transporter 2 PrintediTyped Name i Month Day Year <br /> >a <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity <br /> ❑Tye ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment TmddNumber: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> tr`�.. Facility's Phone: <br /> y0y 172.Signature of Alternate Facility(or Generator) Month Day Year <br /> K <br /> r3 <br /> N: <br /> L1 <br /> T 1&�e ra ed <br /> Facility Owner or Operator:Certification of receipt of materials coveretla the shipping{aping document except as noted in Item 17a <br /> Name <br /> � t Signatu Month Day Year <br /> �' � DESIGNATED FACIUTYTO GENERATOR <br />