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SHIPPING i•Generator ID Number r2. age 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT _ (877) 577-2669 417104460BOL <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Ptfr'Sh 1.15#MfZ�122 <br /> —? '' 2203 Grand Canal <br /> 2203 Grand Canal <br /> (209) Stockton, CA 95207 Stockton, CA 95207 <br /> Generator's Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name ItlNs(�lt�1 11719"24 <br /> Stericycle Specialty taste Solutions Inc <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and Site Address 21 St Cent ury Env iron III entaI Of CA U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facili 's Phone: <br /> 10.Containers 11.Total 12.Unit <br /> ga• 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) Wt.Nol. <br /> HM No. Type Quantity <br /> o universal Waste Electronic Device(s) 3 DF 00203 F' <br /> a <br /> Z 6niversal Waste Electronic Device(s) 1 CF 00016 P <br /> C5 <br /> 3. <br /> ri llr✓riirr <br /> ""rr /i7 r ih�r r <br /> 4. r��,�r✓�lrr�4r��iiirr� , <br /> r��r'j✓r"lrrr�ri'r��r�r���,��pr✓�1��1 r��/'M"' <br /> ' Y rrv�r�r��rr�r✓i��Jrry���r��(i1lrr��i"� �" Pr'l <br /> 13.Special Handling Instructions and Additional Information 1. 102335(BOL — Universal Electronics) c. 102335(BOL — Universale <br /> Electronics) <br /> 14.GENERATOR'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,marked and labeled/placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Signature �__ Month Day Year <br /> Generator's/ fferor'sPrinted/Typed ame syn beha f Df <br /> c <br /> 15.Inte national Shipments 1:1 Import to U.S. ElExport from U.S. Port of entry/exit: <br /> ZDate leavin U.S.: <br /> — Trans orter Signature for exports only): <br /> W 16.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> Transporter 1 Printed/Typed Name Signature <br /> M 03 130. <br /> RL Kristopher Almanza Month Day Year <br /> Transporter 2 Printed/Typed Name Signature <br /> ccF <br /> 17.Discrepancy <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 17a.Discrepancy Indication Space <br /> El Quantity ❑Type <br /> Shipment Tracking Number: <br /> U.S.EPA ID Number <br /> 17b.Alternate Facility(or Generator) <br /> J <br /> U <br /> if Facility's Phone: Month Day Year <br /> W 17c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> (7 <br /> U) <br /> W <br /> D <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a Month Day Year <br /> Signature <br /> Printed1 yped Name <br /> 1 � <br /> DESIGN ED FACILITY TO GENERATOR <br /> 169-BLC-0(Rev.5-11) <br />