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SHIPPING 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Shipment Tracking Number <br /> 0MUMEW CAL000376262 1 1 18775772669 408809170BOL <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Dollar General #14130 Dollar General#14130 <br /> 2097749073 4115 N EL DORADO ST 4115 N EL DORADO ST <br /> Generator's Phone:209774 STOCKTON, CA 95204-2104 STOCKTON, CA 95204-2104 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <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 /> Facift's Phone: <br /> CAR000210617 <br /> 9a' 96.U.S.DOT Description(including Proper Shipp ng Name,Hazard Class,ID Number,and Packing Group(if any)) 1'] Containers 11 Total 12.Unit <br /> HM No. Type Quantity WtJVoI. <br /> 1Consuser Electronics for ecycling (General E- 1 DM 00037 A . _ <br /> o Waste), <br /> ` 3' r . <br /> W 2. - <br /> - <br /> ...rY:• <br /> 4. <br /> 13. Special Handling Instructions and Additional Information 1. 11 48( 'onsuner t1eetron1es for ecyc1ing) <br /> 1/7 fl --- <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 labeledrplacarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulkttions. <br /> GeneraJOHeroes Printedlryped Name Signature <br /> r Month Day Year <br /> _ 15.Intez107 111 4017natio I Shipments 1 <br /> Z ❑Import to U.S. ❑Export from U.S. ly kxit <br /> Transporter Siqnature(for exports only): Data ieaori U.S.: <br /> Ir Lu <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signalu <br /> yIsidro Martinez _ Month Day Year <br /> 107 111 4017 <br /> HZ Transporter 2 Printed/Typed Name Signature <br /> I Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space 11 <br /> Quantity Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Number: <br /> 17b.Alternate Facility(or Generator) ShinmentT—led o <br /> U.S.EPA ID Number <br /> J <br /> U <br /> uR_ Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) <br /> Mm <br /> on Day Year <br /> _ I <br /> ..s�,_.s�8:� ;:'-`.ter.•.a�::;!._z�-::_-. ..�...:r.•��5.�...`:: -_ ----- �'k5i:. •••- <br /> Q _•.i• r.::r_`-; ..:: ::,=5r- - <br /> x+» --,:a11:F?� .....:. .... .... s�rr.-_• b,.... ....�r... ;,r. _ _ •.ri. .—=.., .3i. - - y,-- - <br /> -..�i::•' .y:_l.�. .:� '-•�:3Sr 1�•= '«�:.«_'.....�.s..4:=L':F��.�'^��"_=> - •.�,. - .... S .fid--E"��i � A. <br /> '�k' ._;e::...;Mks......i:-nr=-�:. r_q.. -7r:::---r_-.: '- '�. _- _ ���.,�_ '�y1 :mks.a,•-�_ - - <br /> •t!- �+i--_;�'.�." ...r�:.... •...u....i'-kms= ��+r;�" ,.� �. - <br /> 18.Desi nated Facili Owner or ._'"_:-.`•-.•--� :::_-,='��::;.;• --.� ���;n: �::r_r�`::�::?�•m-''�-:::� _ -y _ �"> <br /> 9 ry Opmator.CargAcatlen of reo"I'l o?rnatedale covered by me stripping docvmani exc"i as noted in Item 17a - <br /> P'ntedlTyped Name Salure <br /> C Month Daffy} Year <br /> 169-BLC-0(Rev 5-11) f <br /> F°6DESIGNATED FACILITY TO GENERATOR <br /> 9-,g -O(rev5-ll)v2CAL20072032 541053295 040880917 M DESIGNATED <br /> SD071117 <br />