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3 �OccD <br /> SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ShipmentTracking Number <br /> DOCUMENT CAL000401815 1 (877) 577-26E9 415143990BOL <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Marshalls #M0122' Marshalls#M0122 <br /> 209-952-7870 2203 Grand Canal 2203 Grand Canal <br /> Generators Phone: (209) Stockton, CA 95207 Stockton CA 95207 <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 /> Facilit's Phone: CAR000210617 <br /> 9z 10.Containers 11.Total 12.Unit <br /> HM gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number,and Packing Group(if any)) No. Type Quantity wt./Vol. <br /> � 1. Universal Waste Electronic Device (s) 2 DF 00118 P <br /> 0 <br /> a <br /> wz 2. Universal Waste Electronic Device (s) 1 CF 0002E P <br /> c� <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Information 1. 102335(BOL — Universal Electronics) 2. 102335(BOL — Universal <br /> }Electronics) /A <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 applicable international and national governmental regulations. <br /> Generator's/Offeror' Printed/Typed Name Signature On a 1 f of TJ Month Day Year <br /> 1 081231211711' <br /> J 15.International Shipments <br /> ( ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Si nature for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed,7yped Name Signature Month Day Year <br /> a- Demarco Brodnaxcn 1 081 23120 1 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Reject n <br /> Shipment TrackinNumber: <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> rai Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 0 <br /> V) <br /> Lu <br /> 18.Designated Facility Owner or Operator:Cer tion of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Printed/Typed Name Signature MA Day e <br /> 169-BLC-0(Rev 5-11) DESIGNATED FAC!!_'" �GENERATOR <br /> i C0—M! f, -,A I-. ,,=_i i l "^rnl A rAtal11 7i ci,r"D11grC� ni�i li%Qq M DntaR-ori n a <br />