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SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT CAL000018659 1 8775772669 413470940BOL <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Kmart #3174 Kmart#3174 <br /> 2099488205 2180 E Mariposa Rd 3180 E Mariposa Rd <br /> Generator's Phone: •� 1 —_ <br /> tock <br /> 6.Transporter 1 Company Name U.S. AID Number <br /> 7.Transporter 2 Company ame U.S. I um YL <br /> er <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21st Century Environmental Of CA <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facili 's Phone: <br /> ga, 10.Containers 11.Total 12.Unit <br /> HM 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) <br /> No. Type Quantity wt./Vol. <br /> cc 1 Universal Waste Fluorescent Lamps 4 CF 00022 P <br /> a <br /> LU <br /> LU <br /> Z 2. <br /> w <br /> cs <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information 1. 100910(Univer5al Fluorescent Lamps) <br /> R C�I — -� I C) o � <br /> 14.GENERATOR'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,marked and labeled/placarded.and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Gener is/Ofieror's Printed/Typed Name �( Signature Month Day Year <br /> 1 International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter Signature for exports only): Date leaving U.S.: <br /> r¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> IL 12 <br /> O <br /> Z Transporter 2 PrintedTyped Name Signature Month Day Year <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ y yp ElPartial Rejection ElFull Rejection Quantit 1:1 T e ❑Residue <br /> Shipment Trackin Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> La Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> S2 <br /> w <br /> w <br /> D <br /> 18.Designated Facility Owner or Operator:krtification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Printed/Typed Name Signature Month qay ar <br /> &A In � I I <br /> Y-C�� 3 <br /> 169-BLC-0(Rev.5-11) DESIGNATED FACILITY TO GENERATOR <br />