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01 - . <br /> SHIPPING 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT CAL000427614 1 8775772669 411747340BOL <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Bath & Body Works 65 Bath & Body Works#65 <br /> 2099524396 5308 PACIFIC AVE, SHERWOOD MALL/ SPACE 6 5308 PACIFIC AVE <br /> Generators Phone:209952 STOCKTON, CA 95207 STOCKTON, CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address PSE; Environmental Sery i ce Pomona, tP U.S.EPA ID Number <br /> 2490 W Pomona Blvd. <br /> Pomona, CA 91768 <br /> Facili 's Phone: CAD983649880 <br /> 9a. 10.Containers 11.Total 12.Unit <br /> HM 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number,and Packing Group(if any)) <br /> No. Type Quantity WI.NoI. <br /> tx <br /> 'Consumer Electronics for Recycling 1 CF 00005 R <br /> 0 <br /> a <br /> tx <br /> w <br /> Z 2. <br /> ul <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Information 1. 111131 (Consumer Electronics for R ec y c l e) <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 /> Generator's/Offerors Printecirryped Name Signatur6RCL rep on behalf of L i■l t e Month Day Year <br /> 4-� 08 09 018 <br /> 15.International hipments <br /> i Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leavin U.S.: <br /> cc w 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name <br /> Signature Month Day Year <br /> COLU) Miguel Ayala 08 09 018 <br /> Transporter 2 Printecirryped Name Signature Month Day Year <br /> tx <br /> I- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment Trackin Number: <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rat Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> • to :: - - _...: - -..: :_._. _._... ._---- _'.. .: .f.'.-.- � -.:::-. '. ..:.. ,_._.. ,:,.::: <br /> w s <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> PrintedrTyped Name Signature Month Day Year <br /> ( A <br /> 169-BLC-0(Rev 5-11) <br /> DESIGNATED FACILITYTO GENERATOR <br /> 15'x-BLC-O{rav5-1!I vICA '�3??8_ 5410671116 . 041174734 M -PDW0+916 SD080918 <br />