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SHIPPING <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shlpm1 . <br /> entTracking Number <br /> 0 <br /> DOCUMENT i r-r 77 7 77 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Bath & Body Wot-t:=_ 1510 Hath E Bodv Wor- sii1510 <br /> 2094729339 4950 PACIFIC AVE, WEBERSTOWN M LL/ SPACE 4950 PACIFIC AVE y <br /> Generators Phone: -liq 1-2 1,13TOUTOM, rA 2 -,'0 9TOUTON 1 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steric cle Specialty Waste Salr_stionE Tnr MNS000110924 ' <br /> 7.Transporter 2 Company Name%� U.S. PA ID Number ? <br /> ✓ �, <br /> 8.Designated Facility Name and Site Address 21 Century MN, LLC U. .EPA ID Number <br /> 2095 Newlands Dr. Eart <br /> Fernley, NV 99408 <br /> Facilit esPhone: 7755752760 NVD980895338 <br /> 10.Containers 11.Total 12.Unit > <br /> HM U.S.DOT Description(including Proper Shippi g Name,Hazard Class,ID Number,and Packing Group(d any)) No Type Quantity wtNol. <br /> �?�<c <br /> 1•['r�ntl�ItrElectronic: EF 00005 �°for Pecyclino 1 <br /> p � . <br /> W <br /> Z 2. <br /> w <br /> c`f <br /> : <br /> 3. ,sy <br /> 4. <br /> 13.Special Handling Instructions and Additional Information 1. 111131 (Consumer E 1 e et r on i e s for Recycle) <br /> `s <br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are lully and accurately describe by the pro r #ing name,and are classified,packaged,marked and labele&placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regul ns. <br /> Ge ratoes/Offeroes PrintekUTypek Name _ Signatu RG 1^ h d l f 0 f L 1 t 1 t e Month Day Year <br /> -- 05 4 MI <br /> 15.International Sh ents <br /> F ❑Import to U.S. ❑Export from U. Portof en fe1CA: <br /> 3 TransporterSt nature forexportsonl : `. at ea U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdnted✓Typed Name 5 nature Month Day Year <br /> O <br /> a <br /> ch Mar-Lr <br /> Transporter 2 Prini"AyedlTyped cc <br /> Name S gnature Mh Day Year <br /> 1- 1�& 4� <br /> 6/ <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space El Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment Tracking Number: <br /> F 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Q <br /> LL Facility's Phone: <br /> w 17C.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z g_ <br /> N s x x _, t'i x._` � "�'s�r '�`'vw�r'w` 2 �'�'r�zRI ". ,"'"_�n'� �3'•r�a" <br /> Lu <br /> ri <br /> 18.Designated Facility Owner or Operator:Certtfication of receipt of materials covered by the shipping document except as noted in Item 17a <br /> PrintedTyped Name Signature onth D <br /> Mni <br /> AN <br /> 169-BLC-0(Rev 5-11) DESI NATJD FACILITYTO GENERATO <br />