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Q VEOLIA <br /> ENVIRONMENTAL SERVICES <br /> SHIPPING 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipping Document Tracking Number <br /> DOCUMENT t~ d 4. 'ek r` Yl�tlt f ZZ <br /> 00797378 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> F>EII?�JL C11fAIX?i+7I3 �� <br /> 5635 EIKM WAY <br /> MkM CIA 955-7217 <br /> Generators Phone: 2 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 7wf� ?ii�JlI.BFRVg.BlI C ,A ? 0 0 0 6 2 4 2 4 7 <br /> 8,Designated Facility Name and Site Addresm w nxxw.AL smunomt U -EPA ID Number <br /> T_Lr. <br /> I'M W.PW3T STIEEEr"f <br /> Facility's Phone: 626 434-5117 kn)SA`CA 91M c A D 0 0 P 3 0 2 A G 3 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Codes <br />- No. Type Quantity Wt.No€. <br /> 1' YJd3]'wyNCC 7t?4.wP,14NO <br /> 1L CAPACIR'V); <br /> WMIT <br /> U, 2. <br /> UJ <br /> C7 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information RIS Uwics Caftoii 49/VMS + ~owl1mg=WwW by VMMMON me&% <br /> .In III itmurA-Alntw ts,9rta s,r ggltwt&*hikfirkrw trawwatillis on pawam*x%beWf. + 1)BRO.126 W:714M A- <br /> 15GENERATOR 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> enerator slOfferor's PrintedlTyped Name Signature Month Day Year <br /> X. 0 1 I 2 <br /> J 15;International Shipments ry ent of 1 <br /> H ❑Import to U.S. ❑Export from U.S. Port exit: <br /> Z Transporter signature for exports onli Date leaving U-S.: <br /> LU 17,Transporter Acknowledgment of Receipt of Shipment <br /> " Transpa.%[.1 PdntedrTyped Name gnature onto ay ear <br /> ZTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> . r- <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Duantl <br /> ty El Type ❑Residue ❑Partial Rejection LJ rill Rejection <br /> Shipping Document Tracking Number: <br /> 18h,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> Facility's Phone: <br /> n18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> rn <br /> 19.Report Management Method Codes(I e.,codes for treatment.disposal.and recycling systems) <br /> a1. 2 3, 4. <br /> 26.Designated Facility Owner or Operator,CeRification of receipt of shipment except as noted in Item 18a <br /> Prinled7Typed Name Signature Month Day Year <br /> GENERATOR 1 SHIPPER'S INITIAL COPY <br />