Laserfiche WebLink
SHIPPING 1CALOOO4236I6 <br /> enerator to Number F877577�66,ge 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT 413030700AOL tl <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Fath & Body Works 1510 Bath & Body Works#k1510 <br /> 2'0947-09339 4950 PACIFIC AVE, WEBERSTOWN MALL! SPACE 4950 PACIFIC AVE <br /> Generator's Phone:209472 STOCKTON CA 95207 STOCKTON CA 95207 # <br /> 6.Transporter 1 Company Name rt? <br /> U.S.EPA ID Number <br /> Stericvcle Specialty Waste Solutions Inc MNS00fc�11094 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address L 1st Century Environmental Of CA U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facii 's Phone: GAROQtQr2'10617 <br /> ga. <br /> HM 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group( 10.Containersf any)) 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> 'Consumer Electronics for Rec clin <br /> o Y 9 i CF 00005 P <br /> a <br /> W <br /> W <br /> Z 2. <br /> UJ <br /> t, <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information 1, 111131(Cons 1_t m er Electronics <br /> for Recycle) <br /> �0 }Ir -(�)0uI(-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,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 /> Generator's/Offerors Printed/Typed Name Signatu n behalf of Limite Month Day Year/t� <br /> 02 01 019 �a <br /> zi 15.International Shipments t <br /> 1- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> — Trans der Signature(for exports only): Date leaving U.S.: <br /> 5 <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> UJ <br /> cc <br /> Transporter 1 Printed/Typed Name Sign Month Day Year <br /> N Jeff Hamilton 02 <br /> ( n 019 <br /> Transporter 2 Printed/Typed Name Signacc Month Day Year ;-`4 <br /> 17. <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shi ment Trackin Number: f ', <br /> F 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U Y <br /> LL Facility's Phone: s'ts <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> w - <br /> o _ <br /> r} <br /> n <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> ` Printed/Typed Name <br /> Signature Month Day(Alt, <br /> T) <br /> 2 <br /> 169 BLC-0(Rev.5-11) = ;r � a#E1 *-.,WI i. <br />