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SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone-, 4.ShipmentTracking Number <br /> DOCUMENT CAL000401815 1 W75772669,­ 4119204P Belt <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Marshalls #M0122 Marshalls#M0122 <br /> 2099527870 2203 Grand Canal 2203 Grand Canal <br /> Generator's PhonM952:.Stockton,, ,CA 95207 Stockton CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNSOM110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 21 s t Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408- <br /> Facilit rs Phone77557527610 NYD98089 5338 <br /> 10.Containers 11.Total 12.Unit <br /> 9a' 9b.U.S.DOT Description(includingProper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) <br /> HM p p pp 9 No. Type Quantity Wt.Nol. <br /> Universal Waste Consumer Electronics for 3F 1173 P <br /> c Recycling <br /> w <br /> Z 2. <br /> ILL! <br /> x <br /> 3. <br /> >y <br /> 4. <br /> 13.Special Handling Instructions and Additional information 1. 102335(Universal Electronics) F <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 applioVe international and national governmental regulations. <br /> Generator's/ r s Pr tekilTyped Name Signa behalf o Month Day Year <br /> , <br /> 2 <br /> x v. ,. c 18 <br /> 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> f— <br /> z <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials x. <br /> W _ Month Day Year <br /> Transporter 1 PrinteVyped Name Signatur <br /> a Melissa,Ballard_ _ + . � �c 18 <br /> z Transporter 2 Printed/Typed Name �11 Signatur Mon/th� Day Yepar <br /> cc 2— �G 0 <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ElResidue EJPartial Rejection ElFull Rejection ., <br /> Shi mentTrackin Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> u¢ Facility's Phone: <br /> LO 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> w �. <br /> a . <br /> 18 Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Priyped Name Signature Month Day Year 1 <br /> ( <br /> 169-BLC-0(Rev 5-11) DESIGNATED FACILI�y T CA ry�jERATCR <br /> 69—BLC—O(rev5-11)v2CAL40000131 540024585 041192042 M PD100218 SL�1 0c 8 <br />