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�I i SSSg <br /> SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.Shipment Tracking Number <br /> DOCUMENT CAL00042/61¢ 1 877577'2663 403246580BOL <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) , <br /> D ali1 GG:JLy W1}rtt Stfl•JlU <br /> 2094 23337 4350 PACIFIC AVE, WCOCRSTOWN MALL/ SPACE 4350 PACIFIC AVE <br /> Generator's Phone z. 1 4 i c O 1 OCK 1 ON, LH 352111 r J 1 OCC 1 ON LH 3:207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 33 tr"iL'vL 1v OUr L'ldlbv Wdh4r OuluL iullS 1110 191V 10oo11@324, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address %r 11 L u r-y u 11 v 1 r-u I i m r 11 t a i u i LH <br /> U.S.EPA ID Number <br /> 11055 WiiiLe RUL:l Rudd <br /> R&iit:ifu LUr'UUVd1 CA 75742 <br /> Facility's Phone: I i'AR0iZ0210101 i <br /> 9a 10.Containers 11.Total 12.Unit <br /> HM gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 2 A 1.!1430201 Pd41.rr'1rh. Ur-v. L'ulll.dllllltlllF.IU Ltlhhlr_L In 1 0000i r' <br /> O <br /> hydr'un1Ur hU11U1 Lr1rLlr'1L1 h1.Ur'd14rJ <br /> W r' hJ/ O CRO1113Y <br /> Z 2, <br /> LU mi UaiC r' C1rl_i.f'U 111 L'h 1 CL' <br /> Ur' Ry 1'11114 1 OF KI V-1 RC1 W.il r' <br /> 3. <br /> 4. <br /> 13.Special Handling Instmctions and Additional Information - <br /> 1. 11KJ3161L1kIL' H-,Kdl lift oeL,6t'r'1 t•S - UW/ 2. 1111.31 %L.0 I I hUHt r r' <br /> Cl eL'l.r'Uii LL'h IUr' Rel.:y L'1L) <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 labeled/placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Gene r tors/OfferorsPrinted yp Name Signat11re.+ i Month Day Year <br /> r ORLL r•ru un urilcti: ui -imll.r <br /> rlh �S 017 13 2 17 <br /> F 15.International S ipments Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> I— Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> Ai _ <br /> a i L11u11 Wcihiilll 2 <br /> Lull _ 03 1J -17 <br /> rrl <br /> Za Transporter 2 Printed/Typed Name Signatur Month Day Year <br /> t- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment Tracking Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> tai Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> O <br /> W <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Prmted/ryped Name Signature Month Day Year <br /> 169-BLC-0(Rev.5-11) DESIGNATED FACILITY TO GENERATOR <br /> J =1-��_;--�•�• L,y�-_ i ;_^Fn .. S'�r-riijr e_•i•v�i=':aC-JC v:�,c,i �i.r gij0;J 31.1 <br />