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9/2/2010 _ 11_50 Remote ID_ 1,2print ID _ ® 7/8
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<br />• MEOICAtL'WAt�STTETRACKI�NpG FORM NUMBER
<br />0e0 Sttericticycie, IN CASE OFROENLG@ fs3
<br />cUl l MTREC1->OO 1 MDirR It tt>osSTO
<br />®i®
<br />1.Generator's Norm, Address and Telephone Number
<br />AJ N:
<br />BEVERLY U STOCKTON 4567
<br />1221 ROS E LA
<br />STOCKTON, CA 95207
<br />(209) 477-2664 4/1/2009
<br />CUSTOWNUUM 6080855-001 Gt11k►sRsmstaanoNs P.
<br />2A. DESCIRPTICIN OF WASTE 28. CONTAINEn TYPE • . 2C, NO. OF 20, YOLK
<br />REGULATED MEDICAL WASTE, n.o.s•,6.2, TS57 - 90 Gal Tub (Bio) (12 cu ft) CONTAINERS
<br />UN 3291, PG II Cm Et
<br />REGULATED MEDICAL WASTE, 11.0.11.,8.2, O cit
<br />QREGULATED MEDICAL WASTE,11.o.s.,6.2, cu Ttp
<br />UN 3291, PG N , 5•
<br />I-- REGULATED MEDICAL. WASTE, ao.s.,6.2
<br />UN 3291, PG II
<br />REGULATED MEDICAL W995.0.s.,6.2,
<br />UN 3291, Ni II
<br />REGULATED MEDICAL WASTE, R.O.s.,6.2, TY15 - 20 Gal Tub (Chemo) (2.7 cu ft)
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, R,o.s.,6.2,
<br />Pharmaceutical waste Cu FL
<br />3. 's G : •1 hereby declare that the contents of this consignmervi are fully and accuritely f
<br />described above by the proper shipping name, and are classified, . marked and riled, and Cu Ft.
<br />are in aN in proper condition for trarispon according to applicable kVMMtionW end national governmItNal isgulaticns. i
<br />4. TRANSPORTER
<br />..Fresno,C& 93722
<br />4136 Mot Swift Ave. This in a ft,ji
<br />1
<br />TRANSPORTER
<br />CERTIFICATION:
<br />Type Narne. V,
<br />5. INTERMEDIATE HANDLER 2 1 TRANSPORTER 2 ADDRESS: Phone#:
<br />INT
<br />n
<br />i /TRANSPORTER
<br />CERTIFICATION:
<br />PrInuType Nano Signature Daft
<br />TENT FACILITY: 1 certify thsEt I have been authotited by the applicable state a0on to
<br />the above inlicyated wa '.In accordance with the requirement 0U1Il�neil,in that author
<br />Nam k . t 6 '2 sip,aare X apt . '
<br />. r r,.-�
<br />�t fi .=i -'i
<br />untreated medical wastes and that I have
<br />6. INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS:
<br />Phone 0:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERnMATION: Receipt of rnedcai waste as describw above.
<br />PrWrWe .:,:
<br />Signature
<br />,fie r:
<br />INC
<br />11C. Alternate
<br />!r'-ITIERICYCLE
<br />sTeRicycLe
<br />' ��
<br />INC
<br />4135 W. SWFT AVE
<br />SM NORMS AVE,
<br />2775 E 2M SMET
<br />FRESNO.CA 93722
<br />NORTH SALT LAKE CITY. UT
<br />SUN VALLEY. CA 21352
<br />VERNON. CA SM23
<br />T93 1. TSIOST25
<br />TS009M
<br />.115
<br />TENT FACILITY: 1 certify thsEt I have been authotited by the applicable state a0on to
<br />the above inlicyated wa '.In accordance with the requirement 0U1Il�neil,in that author
<br />Nam k . t 6 '2 sip,aare X apt . '
<br />. r r,.-�
<br />�t fi .=i -'i
<br />untreated medical wastes and that I have
<br />
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