Laserfiche WebLink
SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone f 4 Shipment Tracking Number <br /> i DOCUMENT CAL000376262 I 1 a775772699 I 4297636 _ABLIt_ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than maiTing address) <br /> Dollar General #14130 Dollar General#14130 <br /> 2097749073 4115 N EL DORADO ST 4115 N EL DORADO ST <br /> Generators Phone: 229774 TON. CA 9 —2104 I A 4°i?A4—?1 Ata <br /> 6.Transporter 1 Company Name T&A ID Number <br /> t ,e r/ R is tv c Ralu`tinns i_n I 4 <br /> 7.Transporter 2 / Fn� '! <br /> 8.Designates FjW4 Name and SO AWress 21st Century EMN, LLC 'U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Favi Phone: 77557527FA NOM <br /> ya 10.Containers 11.Total 12.Unit <br /> HM 9b.U.S.DOT Description(rx kdng Proper Shipping Name,Hazard pass,ID Number,and Pad"cram(ifany)) <br /> Na Type Quantity mNcl• <br /> rr ''Consumer Electronics for Recycling (General E— 2 DM 00080 P <br /> Waste), <br /> s <br /> W <br /> W 2. <br /> a <br /> 3. <br /> 4. <br /> 13.Special Ham"nstn0onsand Additional Information 1. 110548(Consumer Electronics for Recycling) <br /> 14.GENERATOR'S CERnFICAT*K*I hereby declare that the contents of this consignawnt are hilt'and acaralaly described aboe by the pry 04PPir9 reme,arm are classifiedt packaged,mAad and Iabekiffilacarded,and <br /> are in al respects m proper conation for transport aoeor ft to applicable international and retorral goaenm W regrrhatorrs. <br /> r'slDfierorsPrint=I(cx <br /> -A' �� /� ,a,, l7 F- - — I Month I Day Year <br /> So <br /> 87 <br /> 15�Ir+leffiational Shipments MPrt❑ to U.S. ❑Export from f/j//J/Port of /alit <br /> Tra woft Signature(tor exports onlv): .(avina U.S.: <br /> cc 16.Transporter AckjvwfedFwd of Receipt of Materials <br /> Transporter 1 Pdnied/Typed Name Month Day Year <br /> O <br /> IL .1 r--yC I 11? I AT 67 <br /> H <br /> Z Transporter 2 F,ededlT Month Day Year <br /> 17.Discrepancy ` <br /> 17a.Discrepancy Ndicaton Space ❑ H ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shlmherd Traddna Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J , <br /> U <br /> u. Facititlls Ph": <br /> 17c.Signature of Aftemate Facility(or Generator) Month Dalt Year <br /> Z I I I <br /> a <br /> y <br /> W <br /> O <br /> 18.Designated Facility Omw or Operator Certification of receipt of materials covered by the shipping doaurherx except as noW in Item 17a <br /> PrintedlTyped Name Signature Month Y <br /> r <br /> M� r //P f '0 f r\/fir <br /> 169 BL -O(Rev 5-11) 0 DESIGNATED FACILITYTO GENERATOR <br />