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r, <br /> SHIPPING 7.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT 41 000 4 276 14 <br /> 5.Generator's Name and Mailing Address Generato s Site Address(if different than mailing ad ress <br /> Bath E Body Works 65 Bath I Body Work=#65 <br /> 209954396 5308 PACIFIC AVE, SHERWOOD WK. / SPACE 6 5308 PACIFIC AVE <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S. PA ID Number <br /> G Tor <br /> 7.Transporter 2 Company Name 7 U.S.EPA ee, <br /> ., <br /> 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> 7755752760 Fernley, NV 89408 NVD9 38 <br /> Facl' s Phone: <br /> ga 10.Containers 11.Total 12.Unit <br /> HM gb U.S.DOT Description(including Proper Shipping Name,Hazard Glass,ID Number,and Packing Gmup(if any)) No. Type Quantity Wt.Nol. <br /> o '-Consumer Electronics for Recycling 1 CF 00011 P <br /> a <br /> U.1 <br /> Z 2. <br /> U.1 <br /> O <br /> 3. <br /> 4. <br /> r <br /> Y <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 abo by a proper rp g ,and classified,packaged,marked and labeled/placarded,and <br /> are in ail respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Gene es/Offemes Printed/rry�pedd Name Signatur" e p Il f of L i m i t e Month Day Year <br /> W A'-&-- <br /> j15.International Ship ents" <br /> ❑Import to U.S. ❑Fort from U.S. Po f il;? Trans iter Si nature fore rts on : <br /> Cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/ryped Name gnature Month Day Year <br /> O <br /> a <br /> to <br /> Z Transporter 2 Pri ted/typed Name z`^ A i Signature Month Dgy ear <br /> r <br /> our <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space <br /> ❑Quantity 1:1 Type El Residue ❑Partial Rejection ❑FuA Rejection <br /> ShipmentTracking Number: <br /> 17b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> ua Facility's Phone: <br /> w17 Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> w .. <br /> 18.Desi nated Facility Own or-Operator:Certification of receipt of materials covered by the shipping document except as oted in It 17a <br /> Printyp d Name Sign re Mgotb p y �Y <br /> V\ l/ <br /> 169-BLC-O(Rev 5-11) DESIGNATED FACILITYTO GENERATOR <br />