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Q VEOIIA <br /> ENVIRONMENTAL SERVICES <br /> } SHIPPING 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Shipping Document Tracking Number <br /> DOCUMENT , . b --iitilt :. ZZ 00797241 <br /> 5. Generators Name and Mailing Address Generators Site Address If different than mailing address) <br /> V;YLOit i 18:a NAL:.ARTNUH UA <br /> IICl6NMA[aiklip3t DW S7 - aT: 700 <br /> M.ACY, r".A 9.5376.1491 -K_V, C. 95376 <br /> Generators Phone: 7j;" <br /> _ fi. Transporter I Company Name U.S. EPA ID Number <br /> 7. Transporter 2 Company Name U S. EPA ID Number <br /> liQ Elis RONsN.ffh2:ti. CF_WiCF3 - <br /> 8. Designated Facility Name and Site Address f ]jjA ES TWFW 77DALk. U.S. EPA ID Number <br /> LL.C, <br /> 1155 WhS= Still <br /> SiU i33 <iifi . RYS.MICMsM. rA WHOi <br /> Factitys Phone: - <br /> 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . 110431 12. Unit <br /> and Peaki Group (ff any)) duan WLNoI. 13. Codes <br /> HM ng No. Type tM/ <br /> y 1 . UNZ?K SAMIRMS. ` LY, F11 LII WiffM ACf3), rJc>Ne <br /> K - E intoe aT :rRA(JE, YAP Ar W cur rptTvll A <br /> U.T.TXAAL WASTE - I D F 2 0 0 F <br /> z 2. _ NOME <br /> 0 - <br /> - <br /> 3. C.oii.. IJk -� ) <br /> UINIVNRSAL. W"n <br /> 7 D F 4D P <br /> 4. <br /> 14. Special Handling Instructions and Additional Information :k. '.:4a� :,.rc. C c:.L.a-wi „v :'ES': <br /> &vwy abda1T ii 11ow w4kgiia cs tsisi •Y tlatRrriam es►3swAtl moratopoul m e" .A,4 lid zo Jt(3. k5A LS- _:: ::t:,r <br /> n:SLM 193613 21 W:16WWL A_4),MIi9 11 IN: so1044 A, CAi-3911-VIZ,, <br />_ 15:1 GENERATOR SIOFFEROR 5 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 tabetedlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/ ernes Pdntedrryped Name Signature Month Day 7eor <br /> X <br /> =j 16. International SMpments <br /> Isis ❑Importto U.S. ❑ FxpoR from U.S. Port of entrylexit: <br /> Transporter signature for exports only): o D D Date leaving U.S.: D <br /> w 17. Transporter Acknowledgment of Receipt of Shipment <br /> Transporter 1 Printed(Typed Name Signature Month Day Year <br /> 136 .441 .; ;V RfICNLE <br /> N <br /> Transporter 2 Printedrryped Name Signature on ay ear <br /> IY <br /> H <br /> i15. Discrepancy <br /> 19a. Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Shipping Document Tracking Number: <br /> 19b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> LL <br /> Facility's Phone: <br /> w 19c. Signature ofAltemate Facility (or Generator) Month Day Year <br /> G <br /> z <br /> (7 19. Report Management Method Codes i.e., codes for treatment, disposal,g ( poral. and recycling systems) <br /> 1 . 2, 3. 4. <br /> 20. Designated Facility Owner or Operator. Certification of receipt of shipment except as noted in Item 18a <br /> 1 Printedfryped Name Signature Monm Day Year <br /> GENERATOR / SHIPPER'S INITIAL COPY <br />