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SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT CAL000427614 1 8775772669 412175470BOL <br /> 5.Generator's Name and Mailing Address Generators Site Address(h different than mailing address) <br /> Bath & Body Works 65 Bath & Body Works#65 <br /> 8e,99524396--a _.:=-530&-PACI FIC%AVE,,SHERWOOD,..MALL/,.SPACE„6,..:;, 53@8.PAC.IF IG-AVE <br /> Generator20 <br /> Generator's Phone. 9952 STOCKTON, CA 9527 STEICKTON, CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steri ycle Specialty Waste Solutions Inc MNS000110924 <br /> B�vmpan e [ /j U.S.ESA 1[1Nu benen3 <br /> 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.eEP•+A IIIDDD Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone:7755752760 NVD980895338 <br /> 10.Containers <br /> 9a' 1 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(d Clny)) l Total 12. <br /> Unit <br /> HM No. Type uantity WLNoI.I. <br /> 'Consumer Electronics for Recycling 1 CF 00006 P J. <br /> w - <br /> W 2 <br /> 3. c <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 above by the proper shipping name,and are classified,packaged,marked and labeled/placarded,and <br /> are in all respects in proper condi lon for transport according to applicable intemational and national governmental regulations. <br /> GeneratorslOfferoes Printed/Typed NameSignatuBRCL re on be i f of L i m i t e Month Day Year <br /> `��o j�itr�c�r1 tai 10 10 018 <br /> 1 15.International Shipments <br /> F- 1:1 Import to U.S- ❑Export from U.S. Port of entry/exit: <br /> — Transporter Signature for exports only): Date leavin U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> H <br /> Transporter 1 Printed/fyoed Name Signature Month Day Year <br /> ccO <br /> N Isidro Martinez I is:,.3• -1 w.9w a <br /> Z ansporter 2 Pr'tedfryped Nam 9naf onthADay r <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 11 Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment Tracking Number: <br /> 17b.Alternate Facility(or Generator) U.S.'EPA ID Number <br /> a <br /> u Facility s Phone: <br /> L 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z42 <br /> o `#� �`=a,�, �-.- F���� � ��s-, '`�°� � � � •��”vex-'''F�^*,� �_-� `�s��� a <br /> s <br /> y <br /> 18.Designated Facility Owner or Operator:Certification of receipt of matelots covered by the shipping document except as noted in hem 17a <br /> Pri edrTyped Name Zighire Month Day Year <br /> 169-BLC-0(Rev.5-11) DESIGNATED FACILITY TO GENERATOR <br />