Laserfiche WebLink
"moi t�wf"!..•fii../'.-'Sf.'iRl'-"C T ti" Y"".:i/%•^/{rL1Jl-flv.F.v[ :� -. a�ii Y:i Vi.[Yv..r -.v - <br /> s:1.I.ey�F�,fit :� "!s .a .f'• .�,..•w� .�:alp/Ii-.�:s IMF'-'•Y=" Mf Lel v�.1'i�..r�-p-•'+w <br /> SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT ICAL000376262 i 18775772669 409307030SOL <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> uollar .teneral #141=0 Dollar General#14130 <br /> 2+ 5 11491 1-3 4115 M EL DORADO S f 4115 N EL DORADO 5T <br /> Generator's Phone 209774 STOCKTON CA 95204-21714 STOCKTON CA '5•_' 4 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steric cle Soecialty Waste Solutions Inc 1 MN 00IAt <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 21st Century Environmental Of CA U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facilitr'sPhone: CARIVIMP1091i7 <br /> 10.Containers <br /> 9a' 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group f an 11.Total 12.Unit <br /> HM P ( 9 Pe PP 9 9 P(i YN <br /> No. Type Quantity Wt.Nol <br /> Consumer Electronics for Recycling (General E— 1 DM 00046 P <br /> aWaste), <br /> Lu <br /> Z <br /> Consumer Electronics for Recycling (General E— 1 CF 00004 P <br /> Waste), <br /> 3. <br /> 4, <br /> 13.Special Handling Instructions and Additional Information 1. 110548(COnsUeler Electronics for Recycling) 2. 110548(consumer <br /> Electronics for Recycling) <br /> �� -13511 <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 clamlied,packaged,marked and labeled/placarded,and <br /> are in all respects in proper condition for transpgrt according to agpk 4qe interp*onal and national governmental regulations. <br /> GenerataeslOtleror' PrName r `\ f Signature Month Day Year <br /> b9 115 2b17 <br /> -j 15.International Sh mems <br /> 11 z mport to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature(for exports only): Date leavina U.S.- <br /> LU 16.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 PrintedRyped Name Month Day Year <br /> o. Isidro Martinez <br /> W 109 115 217 <br /> Z Transporter 2 Printed/Typed Name Signature <br /> ¢< Month Day Year <br /> t- I I 1 1 <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ShiomentTradkine Number: <br /> 17b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> J <br /> Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> coa I 1 I 1 <br /> z <br /> Lu <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 4,Ar� Dc,�-,,�.�1 I 1� _ I g IZ 1 11-7 <br /> 169-BLC O(Rev 5-11) DESIGNATED FACILITY TO GENERATOR <br /> iF. -A1 C'—fAt.t�a,u r-1i )v;=CAC +f110t7 X01 ._ <br /> 1;41iAS-+PC41.__ Ln40431717J71 __: I'd _ _ - GT)Qr4tF;17 ____..GT1r7Ir1.1.%17- — <br />