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°Date:08t22/2012 Time:07:21 PM To: 2094636910 From:Patrice Rogers Page 2/3 <br /> 04"0 StedcydW IN CASE OF EMERGENCY COMACF CHEWKC 14OG42443Wr«••_..-.-- ---DEBT 001-1005-M�_• <br /> °•® ""'�'"''`'°�`'"` Route #.- 100 - 10 CUSTWER NO.21132 NDFROOBKRP <br /> ,.Geneeat®I-$Name,Address and Telephone Hurnber <br /> ATTN., <br /> GOLDEN LIVING GE IDE <br /> 2740 1 CALIFORNIA ST. <br /> sIMIMN, CA 95204 <br /> (209) 466-3522 11!102011 <br /> CU57=10t MUNAM 6080848-001 G aUT REOMMYM <br /> 2A.DESCRWMN OF WASH W. CQNTAWER TYPE 2C.111%OF 20. VOUME <br /> UN3291, CONTUMMS <br /> 6.2.PGII M7 - 90 Gal Tub (Biot (12 cu tt1 Cu FL <br /> B I. ReptrWedMemYrs. s, T1349 - 37 Gal Tub (Bio/ (4.9 Cu ft) Cu Ft <br /> RWAW 11111111"Waft 44 Gal Tub(Dio' (S.9 Cu tt> Cu Ft. <br /> 82. T01 - 1, ( (2.7 au ft) Cu Ft <br /> • 20 Gal (Path) (2.7 ) Cu Ft. <br /> _ 20 eal Tub (che") 42. ft) Cu Ft. <br /> 2.MW <br /> Cu Ft. <br /> rharnaceutLc4 <br /> 3.Oeneretor's Ce rWicallm:7 hereby declare that the conterns of this consiprotieM hue fumy and scaltatety TOTALS0- <br /> deSabW <br /> Cu Fl. <br /> abaue by ttte name.attd ate classttied,padagecl,marked and ftbeftdAA=rdetd,ared <br /> ate In alt respects In ition for transport accordutp to applicable Btternadonai and national 9mmmen dons'AK <br /> i <br /> l re Ilial§ <br /> 4.TRANSPORTER 1 SS: Phone <br /> Stericycle, nc. This fa a Through Shipment ApplicablePerrrrttNWWMM: <br /> 4135 t Swift Ave. Hauler Rag# 3400 <br /> Fresno,Ca 93722 <br /> i TRANSPO CERTIFICATION:Receipt of mewl waste as <br /> PrInt/iype Name Date <br /> S.INTERMEIDIAIWWWDLER 2 i1TVAMPORTER 2 Ptwrte M. <br /> AppMrabte hermit Numbers: <br /> I .INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Flowipt of modk*l waste as described above. <br /> PrinUType Name Signature Date <br /> I <br /> i ss S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0: <br /> i Applicable Permlt Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Reselpt of me(ficat waste as described above. <br /> Ptint/Type Nam* Signator* We <br /> 7.DISCREPANCY INDICATION <br /> j CU 9 tO: W01ttt Sall LAO.UT <br /> pill, <br /> Fadaty: 0 Favi ty: sC. Facility: W.Aftnuts Facility: <br /> Inc-A Ina•I Sbe Inc-A -AuWdm SWSFTAVE SONAVE SON111 WEST 1345 C 2776 26THSTREETFRESNO.CA 93722N SALT LAKE CITY.UT Sen CA 94577 VERNON.CA 9 43 <br /> (558)275- 1121 t ` D S3 <br /> (801)M- 1555 (SID)SO-2177 (323)362-3 0M <br /> P DALE <br /> �i�11t7� i t t -36 T1fT a -2t3 <br /> TREATMENT FACILITY:I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br /> received the abolRol c�te� in accordance with the requirement out fined in that authorization. <br /> I <br /> Prk*TypeName ryry((JJ1yj Slprrature Date <br /> r <br /> eel Sf6 <br />