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a <br /> SHIPPING 7GeeneArator ID Number 2.Pa 1 of 3.Einer ncv Response Phone 4.5hipment hacking Number <br /> DOCUMENT 008427614 8775772669 411210160BOL <br /> 5.Generator's Name and Mailing Address Generator's Site Address(I different than maili address) <br /> Bath A Body Works 65 Bath A ody Works#65 <br /> 2099524396 5308 PACIFIC AVE, SHERWOOD MALL/ SPACE 6 5308 PACIFIC AVE <br /> Generators Phone: 209952 STOCKTOH, CA 95207 STOCKMR, CA 95207 <br /> 6.Transporter 1 Compo Namer U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Ina MKI38"11M4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Numbersm;� (. - <br /> itts f- 216 3 Va 1-23 <br /> 8.Designated Facility Name and Site Address r U.S.EPATD Number <br /> 2095 Newlands Dr. East <br /> Fernley, HV 89408 <br /> Facility's Phone: <br /> 7755752760 KVD980895338 <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)) No. Type Quantity wt.Nol. <br /> 1. onsuoer ec ron as lar KeCyCilng <br /> W 2. <br /> 3. <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 dassifled,packaged,marked end labeled'placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Gene SiOfleror's Printed/Typed Name Signature S rep onehalf�to Month Day Year <br /> 85 31121 <br /> 15.Wnafoa Shipments <br /> F ❑Import to U.S. ElExport from U.S. Port of entry/ext <br /> K Transporter Signature for exports only): Date leaving U.S.: <br /> LU <br /> 16.Transporter Admowledgment of Receipt of Materials <br /> Transporter I Printed�Typed Name Signature Month Day Year <br /> ° Wniel Lee 05 31 201 <br /> W <br /> z Transporter 2 Printed/Typed Name SignaMonth Day Year <br /> cc 114- <br /> 17.Discrepancy 77, <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Shipment TrackinNumber: <br /> 17b.Alternate Facility(cr Generator) U.S.EPA ID Number <br /> v <br /> _J <br /> U S3� <br /> LL Facllitys Phone: <br /> 17x.Signature of Alternate Facility(or Generator) Month Day Yea( <br /> a <br /> z <br /> ,� <br /> MA <br /> Mh <br /> 18 Designated Facility Owner or Operator:Cetricatlon of receipt of materials co ered by the shipping document except as noted in Item 17a <br /> Pnnted/Typed Name Sign lure y nth <br /> 169$LC-O(Rev 5-11) 1DESIGN�AT D FACILITY TO GENERAT6R <br /> =169-BLC'0(rev5-11)v2C8293378 S41067815 041121016 )y P 11R SD093118 <br /> t. <br />