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SHIPPING 1.Generati I umber <br /> DOCUMENT 2.Page 1 of 3.Emergency Response Plrone <br /> 1 AL0004 7 t 4 4.ShfpmardTrac ng Number <br /> 5.Generators Name and Mailing Address _ J 1 97'�1 <br /> 5,72663 {:141_1770BFJL <br /> Bath ax 1,53c;' wor-ks <br /> Generator's Site Address(if different than mailing address) <br /> 20-995 <br /> 6`� <br /> 11 <br /> 4 = rI: 3�=�t7 X- it <br /> dy <br /> OAVE. HERWOO; MALL/ SPPCFE 5s�8 '4�I <br /> FI C AVE Phone: ''03306 ST , CA <br /> 6.Transporter 1 Company Name S T DC-FTON,r Cts <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name t T f`_ J <br /> U.S.EPA to Number <br /> 8.Designated Facility Name and Site Address T1 v 1 ^O P.re7iT a L IJ , <br /> 11855 White Rock Road U.S.EPA ID Number <br /> 5-.s` <br /> Facil' `s Phone: <br /> 9a. CA 800021 @61 <br /> HM 9b.U.S.DOT Descdpfion(including Proper Shipping Name,Hazard Class,ID Number.and Packing Group(if any)) 10.Containers <br /> 11.Total 12.Unit ` <br /> O 1. C..9 T1_r_l 0 a i' �. p^,r 0 ri'r: O r^ .;e e7 r ,r I No. Type Quantic <br /> y WtNol. <br /> ¢ -F Z! SsZIi p <br /> s <br /> W <br /> W 2. <br /> E <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> _..814^ <br /> 3 <br /> 14.GENERATOR'S CERTIFICATION;I hereby declare that the contents of this consignment are fully and accurately described abo t Propership <br /> are in all respects in proper condition for transport accordin to <br /> Gene r's/Offeror's Printed/T 9 appkcable international and national P and are classified,packaged.marked and!abeledtplacarded,and <br /> yped Name governmental regulations. <br /> Signatures ,L e p h If of ` <br /> r, 15.International Ship. Is I I f 2 Month Day Year <br /> ~ ❑Import to U.S. k:_ <br /> ran =S 13 <br /> Z Trter Signature for ex <br /> ports <br /> on Export From U.S. Port of entry/ <br /> 16.Transporter Acknowledgment of Receipt of Materials Date le <br /> U.S.: <br /> (�r— Transporter 1 Print typed Name <br /> 0. ArthG;. Mack <br /> Si ature' <br /> a Transporter 2 Printed/ryped Name Month Day yea, <br /> ¢ Signature 05 ;1S 1L7r I.S <br /> 17.Discrepancy <br /> Month Day Year <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity <br /> Type ❑Residue <br /> ❑Partial Rejection <br /> ❑Full Rejection <br /> >- 17b.Alternate Facility(or Generator) <br /> 7 Shr mentTrackirt Number: <br /> U U.S.EPA ID Number <br /> w Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) <br /> 2 <br /> 0 <br /> w Month Day Year <br /> 0 <br /> 18.Designated Facility Owner or Operator:C kation of receipt of materials covered by the stepping document except as noted in Item 17a <br /> PrintediTyped Name <br /> Signature <br /> 169-BLC-O(Rev 5-11) A4 th Day 'ear <br /> DESIGNATED FACILITY TO GENERATOR <br />