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-- --MEDICAL WASTE TRACKINGFORM NUMBER <br />QtpO Bi"iC'j►Gi2° IN CASE OF EMERGENCY CONTACT -9300 STANDARDMANIFE8T00i•19.0&8TD <br />rie,e *0reopds >c,af AI141, u..,.+e ar . I o'> — yr GU8TOt4tt3R N0.2t132 <br />r <br />.� <br />Generator's Name, Address and Telephone Number <br />ATTN: rank Juarez <br />n- LMfiAVET1 CARE CEMR <br />6940 PACXFXC AVE <br />sTocnox, CA 9.5207— 2602 <br />CUSTOMun wumoot rnon <br />uen ewneuw n ncu,a i nfln�n n <br />2A, DESCRIPTION OFVIASTS 2g. .. CONTAINERTYPE 20. NO- OF 2D. VOLUME <br />CONTAINERS <br />k6.2, <br />3229911- Rapulat6d RlsdicalWasitr, n,os„ Cu Ft <br />3291 Re6ulatedMadfealWasie,n.os, Cu Ft <br />PGII TB4 — 37 Gal Tull Bd.d 4.9 01 <br />Ut1329L Reautal0d Medlwi t"fasle, n 9.s., � f �[ ,,., �, <br />B.Z,puli I Tri.La — _UJI lidA 6'idiJ na V/ i7. c:u r vI V -... - <br />8ff29i Rc9utatedhiedlcalWasle,n,os., T32i,(sza}IxP15- (Path!/TX15—WIlletao)20 1341 TUb(2.7GUFT) Cu Ft <br />R.2- Pt311 <br />0194, <br />6Is31� B <br />n.o S, <br />n.o.s., <br />3. Genorotoes Certification: 11 hereby declare (hat the contents or this consignment are fully and <br />dq,%a bove by the proper shipping name, and are dessi0ed, packaged, marked and labbitedl <br />e th all r peels in proper con trop rot transport according to applicable International and nation <br />ped Name v�?.LPr1n'ls <br />TER 1 ADDRESS. <br />Stericycle, Inc. ❑ This in a <br />0 <br />4135 V. Swift Ave �} <br />1: resno,CA 93722 / r� <br />medical waste as desc6i:�—! <br />y? ; <br />�3 3lnnafure _ <br />TOTALS 110- <br />and <br />ental ?W labons, <br />V Phone If: r <br />Shipment Applicable PQrtl §hj,%jis <br />—7422 <br />Hauler R`eg# 3400(r <br />W <br />t/ttrr 2INAL — <br />ti. INTERMEDIATE HANDLER 2 / RAN PORTER 2 ADDRESS: <br />Phone 8: <br />Nw <br />} <br />Applicable Permit Numbers. <br />8 <br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of mewl waste as described above. <br />t� <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> V'! <br />' <br />TREAT ENT F!�§rlifl'I YAI\�1 f tj>rgoI ave be n authorized by the applicable state agency to accept untreated medical <br />1i''nrd7ltcaiiedi�^as'ltes in that <br />wastes and that I have <br />receive,the above In accorda ce with the requirement <br />outlined authorization. <br />Prtnlltyp Nam® Sfonatura <br />Date <br />t/ttrr 2INAL — <br />