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SHIPPING <br />1 •Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Shipment Tracking Number <br />DOCUMENT <br />CI L00(3425714 <br />1 <br />( (177) 577-2669 <br />1 4109137MOBOL <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Petco -- 1291 Petco#1291 <br />209-263-6107 . 2350 W. KETTLEMM LANE SUITE 120 2350 <br />W. KETTLEMAN LANE SUITE 120 <br />Generator's Phone: ( 209) Lodi CA ,r 95242 Lodi, <br />CA 95242 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />Stericycle Specialty Waste Solutions Inc <br />MNS000110924 <br />7. Transporter 2 Company Name/ � , 0 � � <br />�...... <br />U.S.���� Number <br />8. Designated Facility Name and Site Address 21st Century EW, LLC <br />U.S. EPA ID Number . <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />Facili 's Phone: 7755752760 <br />NVD980895338 <br />9a <br />HM <br />9b• U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) <br />10. Containers <br />11. Total <br />12. Unit <br />No <br />Type <br />Quantity <br />Wtivol. <br />'.Universal Waste '- Lamps (Fluorescent Light <br />1 <br />CF <br />001)15 <br />P <br />aTubes), <br />a <br />W <br />Z <br />2 -Non -Regulated aste Electronic evices), <br />1 <br />CF <br />OW3 <br />P <br />3. <br />4. <br />13. Special Handling Instructions and Additional Information 1. 103585 (Fluorescent Light <br />Tubes, Whole (Universal Waste)) 2. <br />103579(Electronic Waste) <br />14. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping n <br />a are cassiGed, packaged, monied and labeledlplarrrded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />Ge I r's/Offeror Printedrryped Name Signatur Beh a l f P <br />CO Day Year <br />if <br />04 1 18 16 <br />F <br />15. International S pme'nts ❑ Import to U.S. Export from U.S. Port <br />of entry/ <br />Transporter Signature for exports only):Date le i U.S. ` <br />W <br />16. Transporter Acknowledgment of Receipt of Materials <br />¢ <br />Transporter 1 Printed(Typed Name Signal a <br />Month Day Year <br />c <br />a <br />rn <br />AnthonyMack <br />04 1 18 18 <br />4 <br />cc <br />Transporter 2 Pdnted/Typed Name Signature <br />A5 4 <br />Month D Year <br />z o'er <br />17. Discrepancy <br />17a. Discrepancy Indication SpacejV <br />❑ Quantity ❑Type 1:1 Residue <br />EJ Partial Rejection ❑Full Rejection <br />Shipment TrackinNumber: <br />17b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />cU <br />a <br />Facility's Phone: <br />w <br />17c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />rs <br />y <br />A <br />18. Designated Facilityer or Operator. Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br />Printedrryped Name <br />SignatuTVfflN%-11Ub1 I r <br />Mo h 3112V," <br />1A1 <br />169-BLC-0 (Rev 5-11) DESIGN TED FdCILITY GENERATOR <br />