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SHIPPING t.Generator ID Number 2.Page 1 of 3-Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT CgL000427616 1 877577`669 <br /> F5. enerator s Name and Mailing Address 409b17070BQL <br /> Generators Site Address(d different than mailing address) <br /> Bath & Body Works 1510 Bath & Body Works#1510 <br /> 094729339 4950 PACIFIC AVE, WEBERSTDWN MALL/ SPACE 4950 PACIFIC AVE <br /> Generator's Phone: nN. , <br /> 07 c <br /> 6.Transporter 1 Company Name ;TnrKTMa 1717 <br /> U.S. PA ID Number <br /> 7.Transpo er 2 Corppany a U.S.EPA ID Number <br /> 8.Desrgnaled Facility Name and Site Add s U.S. PAID Number <br /> 21st Century EMN, LLC <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Fadli 's Phone: <br /> HM9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(it any)) 10.Containers- 11.Total 12.Unit <br /> No, Type Quantity Wt.Nol. <br /> a '-Consumer Electronics for Recycling 1 CF 00001 P <br /> a <br /> w <br /> Z 2. <br /> (7 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> 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 above by the proper shipping name,and are classified,packaged,marked and Iabe <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulalio s led/placarded,and <br /> Generalcies/Q(feror's Printed/Typ Name Signatur <br /> RC re p/o be f of Limite Month Day Year <br /> . 15.international Ship nts d <br /> Z.j EJ Transporter Signature exports only): <br /> Import to U.S. ❑Export from U. Port of entry/exit: <br /> — <br /> UM 16.Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br /> Transporter 1 Printed/Typed Name <br /> p Signatur <br /> N Month Day Year <br /> Z Transporter 2 ri <br /> Signa <br /> 1— Mont Day Year <br /> 17.Discrepancy l) <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue <br /> Partial Rejection ❑Full Rejection <br /> 17b.Alternate Fadlity(or Generator) Shi ment Tracki Number: <br /> � U.S.EPA ID Number <br /> U <br /> ua. Facility's Phone: <br /> ow <br /> F17c-Signature of Aftemate Facility(or Generator) <br /> Z Month Day Year <br /> C7 <br /> ul <br /> rn , <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered byfthe shipping document except as noted in Item 17a <br /> Printed/Typed Nam <br /> �,e J r `>,�� � Signature Month Day Year <br /> LtJ - ' { <br /> 169-BLC-0(Rev 5-11) 1 U f< <br /> DESIGNATED FACILITY TO GENERATOR <br />