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W <br /> PPfNG 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.SnlpmentTracking Number <br /> UMENT ` <br /> �5.C-Aemtoes Name and Mailing A ress Genera o s ite ress`(iF different than mailing a rens <br /> Bath & Body Works 1510 Bath & Body Works#1510 <br /> 2094729'339 4950 PACIFIC AVE, WEBERSTOWN LL/ SPACE 4950 PACIFIC AVE <br /> Generators Phone: <br /> 6.Transporter 1 Company arae A I umber <br /> e <br /> 7.Transporter 2 Company Name _ U.S.EPA ID Number <br /> /Y/Y:-41w.� /�m4�' /ma c �' /!l0 &t'P?1-0.3P <br /> 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facilil es Phone: 77S979P ISO <br /> 9a. 10.Containers 11.Total 12.Unit <br /> HM 96.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(H any)) No. Type Quantity "]Vol. <br /> o Consumer Electronics for Recycling 1 CF 00015 P t <br /> a <br /> ¢ <br /> w <br /> z 2. <br /> w <br /> O <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information 1. 111131 (Consumer Electronics for Recycle) <br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described ve the proper shipping n 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 regula'ns. <br /> Ge ratorslC>fferor's Printed/Typed Nam Signatu Month Day Year <br /> �=L re f of Li®ite <br /> 15.International Ship is <br /> I— ❑Import to U.$. ❑Export from U.S. Port ofentry/ ' <br /> Transporter Signature tfor exports on : Date leav U.S <br /> Ir 16.Transporter Acknowledgment of Receipt of Materials <br /> T' Transporter 1 Printed(Typed Name Si azure Month Day Year <br /> O <br /> a <br /> Co a Transpo r n ame �`��y / Signature <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ElFull Re'Quantity El ❑Residue ❑Partial Rejection lection <br /> Shi menf Traddn Number: <br /> M.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J , <br /> U <br /> Loci Facility's Phone: <br /> m 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Prime a ame Signa Month Y <br /> n,� <br /> 169-BLC-0(Rev 5-11) — DESIGNATED FACILITY TO GENERATOR <br />