Laserfiche WebLink
169-PLC-0(rev5-11)v`�flL <br /> SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT GLeni 0181�r 1 77577.669 4 i 3E0 5r40PC1L <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Marshalls #M0122 Mara-a-haII s 010122 <br /> 2099527670 2203 Grand Canal 2203 Grand Canal <br /> Generator'sPhon—i Stockton, CA 95aQ7 Stockton Cfl :J"71� <br /> U.S.EPA ID Number <br /> 6,Transporter 1 Company Name <br /> Stericvcle Specialty Waste Solutions Inc 1N9000110924 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and Site Address.` U.S.EPA ID Number <br /> 1st Century 4f CA <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95740 <br /> j <br /> Facili 's Phone: <br /> 10.Containers 11.Total 12.Unit <br /> 9a' 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number,and Packing Group(if any)) No. Type Quantity W1.Nol, <br /> HM y <br /> 1. = F 00021 1 E=` <br /> cc niversal Waste Electronic Device(s) <br /> 0 <br /> a <br /> Lu <br /> Lu 2 F 00195 P <br /> � niversl Wa <br /> aste Electronic Devices) <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Informationl. 102335(PQL - Universa] E 1 e ct r o n i c s) 2. 100335(AUL - Universal <br /> Electronics) <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,anc <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. Month Day Year <br /> Gene raI srOfteror's Printed/Typed Name Sign r�e h a 1 f TJX _ <br /> f �1 <br /> J 15.International Shipments 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Date leaving U.S.: <br /> Transporter Signature for exports only): <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> w Month Day Year <br /> Signature <br /> Transporter 1 Printed'Typed Name <br /> O J" <br /> a <br /> N Signature Month Day Year <br /> Z Transporter 2 Printed/Typed Name <br /> : a <br /> ErI- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity Type <br /> Residue ❑Partial Rejection EJFullRejection <br /> ❑ ❑ <br /> Shipment TrackinNumber: <br /> U.S.EPA ID Number <br /> r 17b.Alternate Facility(or Generator) <br /> F <br /> J <br /> U <br /> I Facility's Phone: Month Day Year <br /> OL 17c.Signature of Alternate Facility(or Generator) <br /> t— <br /> a <br /> Z <br /> 0 <br /> N <br /> w <br /> o <br /> 18.Designated Facility Owner or Operator:Ce ification of receipt of materials cove�bythee hipping document except as noted in Item 17a <br /> Signature fponih Day, at <br /> Printed Typed Nam <br /> 169-BLC-0(Rev 5-11) DESIGNATED FACILITY TO GENERATOR <br />