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SHIPMENT PING 1.Generator ID Number 2.Page 1 of 3.Emergency Responsebone <br /> DOCUP4.ShipmentTracking Number <br /> 5.Generator's Name and Mailing Address ' i 7,1:_1 I k1OBDI <br /> Generator's Site Address(if different than mailing address) <br /> Bath e <br /> �JJJ� WEBERSTOWN MALL; SPgCE 49 ' _ ►-dot �-� :'if3 <br /> 4950 PACIFIC qVE <br /> - � X471 FrrCtFIC P:' <br /> Generators Phone: -_.�a.3472 5TO%F';T ONCA ?=�rZf7 <br /> 6.Transporter 1 Company Name ST j,C4;TOhI, r JAY <br /> ? <br /> U.S.EPA ID Number <br /> S4er'acycie � ,a y t ,c_ l�y Was e SD�I_r}bDn- It•c <br /> 7.Transporter 2 Company Name Imo",IS00i-�);1 o 7 if <br /> w <br /> U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address -' =t- �_.-+. ,, <br /> - --� �-•l'=-..",` Er+lr'r+^cr-._rr�1 z¢ .-� U-S.EPAIDNumber <br /> 1195 WI-rite Rock Read <br /> Ran:h D Cord e a, CF. 95762 <br /> Facili 's Phone: <br /> CA R�I0021 lav 17 <br /> 9a' 9b.U.S.DOT Description includ°n Proper Shipping 10.Containers <br /> HM p ( 9 Pe piling Name,Hazard Class;ID Number,and Packing Group(if any)) 11.Total 12.Unit <br /> I C 0 n S t_f 7f t'r _,c C t r n n i C= forr R`• 7 i 1 No. Type Quantity Wt./Vol. <br /> O r G cc- 00INS P <br /> W <br /> ui 2. <br /> C7 <br /> 3. <br /> 4. <br /> 13.Special Handling Inst Mons and Additional Information _ <br /> or <br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above b proper shi name,and are classified,packaged,marked and labeled/placarded,and <br /> are in all respects in proper Typedcondition for tmrl�orI according to applicable international and national govemmentai regulations. <br /> Ge tols/Offerors Printed/Typed m <br /> Signature-4-6—. L r t <br /> rep half 0: L T i -e Month Day Year <br /> 1 .Int mational Ship nts = <br /> F ❑Import to U.S. t_8 '@'1 <br /> Z Trans orter Si nature for ex orfs- ❑Export from U.S. Port of atry/e' <br /> W 16. Transporter Acknowledgment of Receipt of Materials Date�vi <br /> 0 Transporter 1 Pdntedlfyped Name <br /> nature <br /> W A Month Day Year <br /> a Transporter 2 Printed/Typed Name <br /> F Signature <br /> Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type <br /> ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> F}- 17b.Alternate Facility(or Generator)) Shi moot Track n Number: <br /> =� U.S.EPA ID Number <br /> U <br /> u- Facility's Phone: <br /> w 17c.Signature of Alternate Facili <br /> a ty(or Generator) <br /> 0 Month Day Yea, <br /> W <br /> O <br /> 16.Designated Facility Owner or Operator:Certification of receipt of materials covered b the shipping <br /> Printed/Typed Name Y piling document except as noted in Item 17a <br /> Signature <br /> 1h Day Year <br /> 169-BLC-0(Rev 5.11) <br /> �EEIGN TE©FACI`I i TO GENERATOR <br />