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SHIPPING 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Shipment Tracking Number <br /> DOCUMENT CAL000427614 1 8775772669 410774440BUL <br /> 5.Generators Name and Mailing Address Generator's 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 /> Generator's Phone: 209952 STOCKTON, CA 95207 STOCKTON, CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc MNSM0110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1�� J X21 a- 9X_vZw33 <br /> S.Designated Facil ty Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facilft es Phone: 7755752760 NVD980895338 <br /> ga 10.Containers 11.Total <br /> HM 9b.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,and Packing Group(if any)) Type Quantity 1 122..Unit nit <br /> 10 <br /> No. <br /> '-Consumer Electronics for Recycling 1 CF 00005 P ` <br /> o a <br /> s <br /> W <br /> 2. I <br /> O <br /> 3. I �.. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> 1. 111131 (Cansumer 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/plararded,and <br /> are in all respects in proper condition for transportaccording to applicable infenkaflonal and national governmental regulaUcns. <br /> Generators✓ erors Printedff ed Name Signature L rep b If of L i M i t e Month Day Year <br /> 040.3 W8 <br /> 15.International tpments <br /> F Import to U.S. Export from U.S. rt of softy/exit: <br /> Z Transporter Signature for exports only): Date leavi U.S.: <br /> s 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Transporter 1 Printed/Typed Name Signature Month Day Peer <br /> a- r e r <br /> 04 103018 <br /> Z Transporter2Pri Signa day Year <br /> a 7 <br /> IX: 7 <br /> 11 <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication SpaceEl <br /> ❑Quantity El Type El Residue El Partial Rejection Full Rejection <br /> Shipment Tracking Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> I Facility's Phone: <br /> UO 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> N <br /> W , <br /> All `c µ <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a <br /> Printed/Typed Name Signature Month Day Year <br /> 169-BLC-0(Rev 5-11) DE1 ATED FACILITYTO GENERATOR <br />