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9/2/2010 11:50 Remote ID_ I rint ID ® 8/8 <br />• ® MEDICALQTWA�S1gT�E TRACKING FORM NUMBER <br />..jSflomalt IN CASE OF MER I it _31►i —. _9E&fM t 800 t M�L' Ru 117Y4 1.10464M 10-08 STD <br />1. " tors Name, Address and Telephone Number 0i 1 I "I'lliloil <br />y MWAU STOCMN #156+7 <br />1221 ROSIKAME LAIM <br />S 111, CA 95207 <br />(209) 477-2664 2/25/2009 <br />6080855-001 <br />Touts REGISIM11to•I A <br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO, OF2D NOWME <br />REGULATED MEDICAL WASTE, mos -.6.2, T857 - 90 Ural Tub (Bio) (12 cu W CONTAINERS <br />UN 3291, PG it <br />Cu Ft. <br />REGULATED MEDICAL WASTE, n.o.s..6.2. 9 CU <br />tt <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, T®L' — 79 Ual TUB tB10i 0.9 cu 1C%) t <br />UN 3291, PG 9 1 S <br />4 REGULATED MEDICAL WASTE, n,os.,6.2, I—V ca 90 <br />LIN 3291. PG 9 <br />W REGULATED MEDICAL WASTE, n.os.,6.2. 20 6&2A Cu <br />MZlUN 3291, PG 11 <br />Vr REGULATED MEDICAL WASTE, n.o.s.,6.2, TY1S — 20 Pal Tub tchmo) 42.7 cu ft) <br />UN 3291, PG 11 <br />REGULATED MEDICAL WASTE, n.os.,6.P, <br />UN 3291. PG 11 <br />Pharmaceutical waste z_ Z 44tj 0.3 LAA- <br />I <br />i 3. Generator's Certification: 9 hereW declare that the contents of this consownent are flay and accurately TOTALS ►fa►' . s described abore <br />by the ww shipping name, and are classified, marked and t riled, and Cu <br />are In all reIn proper n for transport to a International and national goverrNontal repuletiorW <br />�._, '11:!:..iri'"r�r .. 7 <br />4. TRANSPORTER 4r*_�4.JFJ0' <br />_ <br />AppkWe Porn* Numbers:4135 Illest Swift Ave. <br />This In a ato ShLipment <br />Fresno,Cn 93722 <br />TRANSPORTER CERTIFICATION: ROCOO of vnedical waft described *W4. <br />V, Rwv.� S,h7 <br />m r <br />ate <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Plhone S. <br />iY <br />�r <br />nINTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: <br />•: <br />joTREATMENT FACILITY: I��UFVOML*9"d by the state agency to accept untreated medical wastes and that 1 haw <br />lreceived the above Indicated wastes in accordance with the retirement outlined In that authorization. <br />PrinVII," Nam®MAR 12:. Signature Date <br />f1®I/A1&t A r <br />s. - ; •IATE Afwx,'ILER 3 ITRAASFIRTERADDRESS: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of inedical waste as described above. <br />,.sillnewre <br />ame <br />,r ata <br />nwu <br />A <br />4136 W. SWFT AVE <br />2053 NORRIS AVE. <br />:i:i is 'R :"Y" <br />•r'. /_ <br />SLIN VALLEY. CA 91 M <br />• <br />TWI.TSAOST25•�: <br />r <br />•. ,:VIr4winiflanPan,­ <br />joTREATMENT FACILITY: I��UFVOML*9"d by the state agency to accept untreated medical wastes and that 1 haw <br />lreceived the above Indicated wastes in accordance with the retirement outlined In that authorization. <br />PrinVII," Nam®MAR 12:. Signature Date <br />f1®I/A1&t A r <br />