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" ��SHIPPING 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Shipment Tracking Number CUMENT _ _ yF _._ 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) _ _- 1, Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number a 8.Designated Facility Name and Site Address _ _ _ -_- U.S.EPA ID Number v' Facility's Phone: � 9a. 9b.U.S.DOT Description(including Proper Shipping 10.Containers 11.Total 12.Unit x HM P ( 9 pe Aping Name,Hazard Class,ID Number,and Packing Group(if any)) No. Type Quantity Wt.Nol.Ix ;` Lu Lu � 2 ht 1 3 � sr�3 '>r. 4. /Z 13.Special Handling Instructions and Additional Information _ i� A id.GENERATOR'S CERTIFICATION:I herebydeclare that the contents of this consignment are full and accurate) described above b the proper t 9 Y y y p per shipping name,and are classified,packaged,marked and labeledlplacarded and are in all respects in proper condition for transport according to appricable intemational and national governmental regulatiopq Jr, r'a G erator's/Offemr' Printedrr Name Signati&v r 1Month Cay Year 15.International ShiprAents Impart to U.S. ❑Export from U.S. Port of entry/exit: I Trans orter Signature fore exports only): Date leavin U.S.: A- m 16.Transporter Acknowledgment of Receipt of Materials %g w 0 Transporter 1 Prints rryped Name Sin Month Day Year N Z Transocrter 2 Printed/ryped Name Signature Month Day Year Cc 17.Discrepancy 17a.Discrepancy Indication Space .� ❑Quantity ❑Type ❑Residue ❑Pariial Rejection ❑Full Rejection f Shipment Trackin Number. 17b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year a Z W O 18-Designated Facility Owner or Operator:Certification of receipt of materials covered by the shipping document except as noted in Item 17a Printed/Typed Name Signature Month Day Year 169-BLC-0(Rev.5-11)