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SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number
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<br /> 5.Generator's Name and Mailing Address Generators Site Address(it different than mailing address)
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<br /> -209--`�52-7870 500 Gt Connecticut Path �t�Q3 Grand �nnal
<br /> Generator's Phone: :- i Y i r•, �? jr
<br /> 6.Transporter 1 Company Name U.S. A ID Number
<br /> U.S.EPA ID Number
<br /> 7.Transporter 2 Company Name
<br /> 8.Designated Facility Name and Site Address r--r;i�t Cent.itr'y Env ir{'�n�s�2C :�- - U.S.EPA ID Number
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<br /> 118 557 E,+h i t e R 0 ii i'(Gc-i6
<br /> Ranct ho Cordova, CA 95742 C _
<br /> Aj�tjj00L i 0Y36f
<br /> Facili 's Phone:
<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 g No. Type Quantity Wt.Nol.
<br /> t ate, tEit=l0248
<br /> i"OFiiC FJ V1�.e {r :a 7F4110
<br /> Z 2.Univer sal waste Electronic Device 's) CF 0006i RLu
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<br /> 3.Un i v G r m a.1 _W _ e Lamps Fl=tut"E scent -r b E (Wi i 0 l t I l 01101
<br /> Fluorescent Tubes),
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<br /> 13.Special Handling Instructions and Additional Information 1. 10 2335(BOL - Universal Electronics) 102335(BAIL Universal
<br /> Electronics) 3. 109943(Universal Fluorescent Light Tubes)
<br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described ab by th proper shipp' g name nd 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 /> Gen oes/Offerors Printed/Typed Name Signature if beh 1 Month Day Year
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<br /> 1 .In national Shipments ❑Import to U.S. 4 ❑Export from U Part of a ry/exit:
<br /> Transporter Si nature for ex orts onl Data] vin U.S.:
<br /> tx 16.Transporter Acknowledgment of Receipt of Materials
<br /> W Signature Month Day Year
<br /> Transporter 1 Printed/Typed Name
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<br /> Z TransporterPri a ype me
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<br /> 17.Discrepancy
<br /> 17a.Discrepancy Indication Space Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection
<br /> ❑
<br /> Shi mentTrackin Number:
<br /> U.S.EPA ID Number
<br /> 17b.Alternate Facility(or Generator)
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<br /> rai Facility's Phone: Month Day Year
<br /> w 17c.Signature of Alternate Facility(or Generator)
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<br /> 18.
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<br /> 18.Designated Facility Ow er or Operator 'fication of receipt of materials covered by the shipping document except as noted in Item 17a M0000ttth D y
<br /> Printed/Typed Nam Signature
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<br /> DESIGNATED FACILITY TO GENERATOR
<br /> 169-BLC-0(Rev 5-11)
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