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SHIPPING 1.Generator ID Nurn er 2.Page f of 3:Emergency Response one 4.5hipmentTracking Number <br /> DOCUMENT 75=2969 <br /> i <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Petco #13J9 Pett #133 <br /> 2094787726 5406 Pacific Avenue 5406 Pacific Avenue <br /> Generator's Phone: 213947a Stockton@ CA 95207 Stockton, <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Spgcialty Waste Solutions Inc MNS000i10924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> lg� —Gr� A ��6 <br /> 8.Designated Facility Name and Site Address" 21st Century EMN,... LLC U.S.EPA ID Number - <br /> M5 Newlands Dt,. East <br /> Fernley, NV 89408 <br /> Faci' s Phone: 775575276$ NVD980895338 <br /> 9a. 10.Containers 11.Total 12.Unit <br /> 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) <br /> HM No. Type Quantity Wt.Nol. <br /> Cr 1-Non—Regulated `EWaste (Electronic Devices) 2 CF 6910122 P .. <br /> 0 <br /> a�. <br /> w <br /> U 2-Universal Waste _ Lamps (Fluorescent light i CF "012 P <br /> Tubes), <br /> 3. <br /> 4 <br /> j <br /> u <br /> 13. Special Handling Instructions and Additional Information 1. 103579(Electronic Waste) 2. 103585(Fluore+sfWent Light Tubes, <br /> Whole (universal Waste)) <br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the pr r shi mg name,and are classified,packaged,marked and lahelecloacarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulatio . <br /> Ge tor'slOfferoes PrintedlTyped Name Signature :hn ef3tco Month Day Year <br /> �---- 04 18 18 <br /> a 1 15.International Ship ents <br /> }.. ❑Importto U.S. ❑Export from .S. Port of a /exit: <br /> Z <br /> Transporter Si nature fore rts onl : D e le U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials w... <br /> Transporter 1 Printed(Typed Name Signa re Month Day Year <br /> N AnthonyMack84, <br /> Transporter 2 Prfnted/ryped NameSignature Month' Day Year <br /> r� � . <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection' <br /> Shipment Tracking Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> LL Facilitys Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) "" Month Day Year <br /> C7 <br /> N <br /> W" <br /> G <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted ij Item 17a <br /> Prinledllyped Name Signatu y <br /> WhLy L <br /> 169-BI-C-O(Rev 6-11) SIG JD D FACILITY TO GENERATOR <br />