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SHIPPING 1.Generator ID Number —re 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT <br /> y ; „ <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phone. <br /> 6.Transporter 1 CompanyName U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number y <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 0 <br /> t j t <br /> Facili 's Phone: <br /> 9a. 10.Containers 11.Total 12.Unit <br /> HM 9b.U.S.60T Description(including Proper Shipping Name.Hazard Class,ID Number.and Packing Group(i(any)} No. Type Quantity Wt./Vol. <br /> Ir <br /> Q <br /> Ir <br /> Z 2. <br /> c7 <br /> 3. <br /> i <br /> r s; 4. <br /> rt;f, <br /> f 13.Special Handling Instntclions and Additional Information <br /> f 1" <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.Dackaged.marked and labetedrplacarded,and <br /> .i <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> b Generatdr'sOfferor`sPrinted/ryped,Name Signature Month Day Year <br /> J 15.International Shipments ` ' <br /> 3A; F- ❑Import to U.S. ❑Export from U S. Port of entrrylexit. <br /> Z Transporter Signature(for exports only): Date leaving U.S.: <br /> a rr 16.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> F Transporter 1 Printedrryped Name Signature {,.% Month Day Year <br /> cc <br /> O <br /> Z Transporter 2 PnntedtTyped Namer SignatureMonth Day Year <br /> cc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication SpaceEl <br /> ❑Quantity El Type El Residue El 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 Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month (( Day Year <br /> Z ` <br /> a <br /> to <br /> LU <br /> 0 <br /> 18.Designated Facility Owner or Operator:,Qertitication of receipt of materials covered by the shipping document except as noted in Item 17a <br /> PrintediTyped Name J Signature Month Day;{ ,Year <br /> 169-BLC-0(Rev.5-141) DESIGIN ,TED FACILITY'S COPY <br />