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4.S h ipment Tracking Number <br /> SHIPPING I-Generator ID Number 2.Page I of 3.Emergency Response Phone <br /> DOCUMENT <br /> i_` <br /> 2 <br /> 5-Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> !T9�0 0Ar-ETr` WE- T f i) <br /> L!-. SPACE C. <br /> Z- EBERSTIE)v -i <br /> r'Q7 <br /> Generators Phone: ;--,:I q-* t <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> a.Designated Facility Name and Site Address U.S.EPA ID Number <br /> hi 11R-.3 R f- <br /> ho Cordova, CA _574 <br /> CA R0 0 0-2'1 <br /> Facilit r's Phone: <br /> 10.Containers 9a- 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class.ID Number,and Packing Group(if any)) 11.Total 112.Unit <br /> HM No. Type Quantity Wt./Vol.. <br /> Ir CE-1 Ccr.-OrlIC S i Rut: LI <br /> 0 <br /> 'A <br /> Z <br /> W 2. <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> .5- <br /> PCH 0 <br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described abo y e proper shippin ilame.aVare classified,packaged.marked and labelediplacarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Ge I O1 &s P intedTyped Name Signature.- 1 Month Day Year <br /> L m t <br /> -1 10 International Shipmenhe Import to U.S. ❑Export from U.S. Port of entry/ I <br /> Transporter Signature(for exports only): Date Vaying <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> cc Transporter I PrintedRyped Name Sig lure Month Day Year <br /> 0 <br /> A J-4 <br /> in <br /> Z Transporter 2 Printedfryped Name Signature Month Day Year <br /> Ir <br /> 17.Discrepancy <br /> 173.Discrepancy Indication Space El Quantity 1:1 Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment Trackino Number: <br /> >- 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> 0 <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> w <br /> 18.Designated Facility Owne-or Operator:CertificaKn of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Signa�e — M th Pay YTar <br /> Inn d,7yped Name <br /> I <br /> 1 69-BLC-0(Rev 5fl 1 <br />