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r,.;209+463+6910 GOLDEN LIVON.JWTA� :39 p.m.1 06-09-2011 5'%MBEI
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<br /> �ericyicle WSE OF EMER( STANDARD MANIFEST 001-10-06-STD
<br /> People.Reftdrig Risk,
<br /> M T)F 1 (.1 AU
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<br /> SERUICE RECEIPT
<br /> enerator's Name,Address and Telephone Number
<br /> Beverly Manor Stockton 1570
<br /> uaSVEPLY MAIIK)F, 5l*'�*'C.K'11*42?141 #fi 70 SERVICE DHTE: 5.3,11 7:06;31 RN
<br /> ORIUIER ID: MRI
<br /> ---- --------------------------------- - -
<br /> kAXA4, CA 4!� 04 CHIPPING HDOCUMENT III: 00FROBHUS!
<br /> .—
<br /> TOIRL COLLECTED: I
<br /> 101RL VOLUME: 5.900 GO FT
<br /> CUSTOMER Numsea f GOROOF8 1111,11
<br /> 1.19 t.t.�1 0 0 1 --------------------- ---
<br /> 2A.DESCRIPTION OF WASTE 28. UGL 2C. NO.OF 20. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., SUMMHRY(Cont Type) Div CF CONTAINERS
<br /> 6.2,PGII T13'1:1 - 90 T914 44 Cal lub(Bin). CT 12.7 1 5 900 Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII TB4'4 37 (441 TIAb DELIVERY-DOCUMENT-1:-POFROUHUSI----------- Cu F
<br /> Ir UN3291,Regulated Medical Waste,mo.s., ------------------------- ------- --------
<br /> 6.2t PGII '631.4 44 Izal Tkib(G 10101 DELIVERED ITEMS: I Cu F
<br /> UN3291,Regulated Medical Waste,ri.o-�-; TB2 3 '20 43al Tiah,(`E;
<br /> 6.2,PGII TYPE OTY Cu F
<br /> LLI UN3291,Regulated Medical Waste,n.o.s.,
<br /> UjZ 6.2,PGII T814 44 Cal Tub(Bio. CI 12.? 111 1
<br /> Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII 11Y-1 20 Gal Tub -------------------------- -------
<br /> Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., 1
<br /> 6.2,PGII DRIIIER: Roth. 41chael Cu F
<br /> UN3291,Regulated Medical Waste,n.o.s., FREQUENCY Euery 2 Weeks
<br /> 6.2,PGII NEXT Pickup: 5-17,11 Cu F
<br /> CUSTOMER SERVICE:
<br /> Thank you for choosing Stpricqcle I
<br /> I I I Cu F
<br /> 3.Generator's Certification;"I hereby declare that the contents of thl: �ALS 0-
<br /> described above by the proper shipping name,and are classified,packmjv�, Cu F
<br /> are in all respects in proper condition for transport according to applicable intematonall and national governmental regulations!
<br /> XPrinted/Typed Name Signature Data
<br /> 4.TRANSPORTER I ADDRESS: Phone lit,
<br /> T.,Be '5 2-1�'
<br /> U.1 .1;'1"r,I:i c'/'.:1.e, E] vii�l j'a a ptrv�l lit Applicable Permit Numbers:
<br /> 4 13 5 rplatryl 'jw j f t- A-v e
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<br /> (0
<br /> Z, TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name ,Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrInt(Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> Z
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrintfType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Transfetred rontainers, cu ft to , North Saft Lake,UT
<br /> ❑8A.Designated Facility: 0 88.Alternate Facility- 8C.Alternate Facility: 8D.Alternate Faidlity:
<br /> Inc-ALAricierve StenqVcle Ino-Inicneration Sitenr.�,de Inc-Autodave Starliqrcle Inc-Auttodwvre
<br /> 4135 V.S'1AFTA*1VE 90 NORTH I I 00'OFEST 1345 DorAtUe Drove Ste C 2776 E 13-TH STREET
<br /> N OPTH SALT LAKE CITY,LJIT San Leandro,CA. 94677 VERNON,CA 90023
<br /> so 11 s3p,- 165r-, (510)562-2177 (323)362-3000
<br /> r-13;'03'1`2:2 IA-448-dA-36 1-13 1 PITS/O.S1125
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> PrinttType Name Signature Date
<br /> I 8--o-
<br />
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