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ix <br /> SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT CAL000427616 1 8775772669 4110110013BOL <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Bath & Body Works 1510 Bath & Bodv Works#1510 <br /> 2094729339 4950 PACIFIC AVE, WEBERSTOWN MALL! SPACE 4950 PACIFIC AVE <br /> Generators Phone: 1109470, T KT N 95207 STOCKTON CA 95`07 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> St—ericvcle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name /'+ _ '_ j Y U.S.S EPA Number'`e?-,ro <br /> 8.Designated Facility Name and Site Address 21st Cent ury EMN, LLC U.S.EPA ID Number r <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facili 's Phone: 7755752760 NVD980895338 <br /> 9a. 10.Containers 11.Total 12.Unit <br /> HM ��U.S.DOT Descriptioni(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> IConsu®er Electronics for Recycling 1 CF 00004 P <br /> o <br /> w <br /> Z ; <br /> c�7 2. x, <br /> 3. <br /> 4. fi � <br /> 13. Special Handling Instructions and Additional information 1. 111131 (Con s <br /> user Electronics for Recycle) <br /> '1/11' <br /> 14.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accuratelydescribed a by a proper sh 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 govemmental re afion <br /> Gen tors/Offemrs Printed/Typed Name Signatur CL rep i f of L i n i t e Month Day Year <br /> 05 101 0018 <br /> J 15.International ShipmVS <br /> ❑ <br /> z Import to U.S. ❑Export from U.S. Port :enl/exd: <br /> Transporter Si nature for exports only): Da Iea U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> t <br /> Transporter 1 PrintedrTyped Name natu <br /> Month Day Year <br /> N g <br /> Anthony Mack TOW) 1 05 lei 0@18 <br /> a Transporter 2 Printedrryped Name 'Sig-nature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space EJ Quantity Quantity ❑Type LI Residue <br /> ❑Par[ial Rejection ❑Full Rejection <br /> 17b.Alternate Facility(a Shipment TrackinNumber:Generator) U.S.EPA ID Number <br /> J <br /> U <br /> tai Facility's Phone: <br /> W 17c.Signature of Aftemate Facility(o(Generator) <br /> G Month Day Year <br /> Z <br /> r _ <br /> F.,. ",. 44'„ •.i _. ... � .a ate- �: � �' �� y1:. c` f` `y ';A� <br /> 18.Designated Facility Owner of Operator:Certification of receipt of materials covered by the shipping document except as ed m Ite 17a <br /> P Name Signal Month D y Y ar <br /> 169-BLC-0(Rev 5-11) <br /> DESIGNATED FACILITYTO GENERATOR <br />