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LI <br /> ENVIRONMENTAL SERVICES <br /> SHIPPING 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. Snipping Document Tracking Number <br /> DOCUMENT _ L ZZto 7 2 11 <br /> 5. Generator's Name and Mailing Address - Generators Site Address (if diRerent than mailing address) <br /> L"- <br /> g Generators Phone: =- <br /> 6& 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 1 .. _ ., <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Add _ U.S. EPA ID Number. <br /> Pact[tys Phone: <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit 13. Codes <br /> HM and Packing Group (if any)) No. Type Quantity WtNol, <br /> cl <br /> O <br /> d <br /> z 2 <br /> _ _ � . . _ <br /> 3 <br /> 4. <br /> 14. Special Handling Instructions and Additional Information p, :. � , wa. , L — <br /> _ r:: . , z.. . . sm , . .. . <br /> IS <br /> 1511 GENERATOR SIOFFEROR 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, <br /> marked and Iabeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulators. <br /> Generator's/Offerors Printedflyped Name Signature Month Day Year <br /> = 16. International Shipments <br /> z 11 Import to U.S. ❑ Expert from U.S. Port of enirylexit: <br /> Transporter signature (for exports only): J rDate leaving U.S.: I <br /> 17.Transporter-Acknowledgment of Receipt of Shipment _ <br /> Transporter ) Printed/Typed NameSignature Month Day Year <br /> 12. <br /> z Transporter2 Printed/Typed Name Signature Month Day Year <br /> Q <br /> F- <br /> 10. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Retrial Rejection ❑ Full Rejection <br /> Sl Document Trackin Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> Q <br /> t— <br /> Facility's Phone: <br /> 18c, Signature of Alternate Facility (or Generator) Month Day Year <br /> Z C <br /> 19. Report Management Method Codes (i.e., codes for treatment, disposal, and recycling systems) <br /> a 1 . 2. 3. 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of shipment except as noted in Item I So <br /> Pnnted(fyped Name Signature Month Day Year <br /> GENERATOR / SHIPPER'S INITIAL COPY <br />