|
•;S e p, 2 8. 2 0 12 4 : 03 PM IN CASE OF EMPRC.I=NCY CONTACT: CHEMTREC 1-800.424.9300 No. 45 5 4,D MAIP, 2001.10 -06 -STD
<br />•! FrawtJagPmpia.Redudn9R1sk.' CUSTOMER N 32
<br />;(,t:�ut:ei -#-.100•• J,8 � L.at'1r`E��ft:'^r1kd�
<br />LEAVE AT rF.NFPATnn
<br />1. Generator's Name, Address and Telephone Number
<br />ATTtj
<br />11Al-IPT011 t::,tiT2E r'ii;tdTEr
<br />44"" k:. F b14rt WI`c'1 Pd -Wil
<br />CA 95 21) d
<br />CummeA NuMeeA 61 o8. '' GENERATOR'S REGISTRATION #
<br />G' •;, -.()0
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291. Regulaled Medical Waste, n.o.s..
<br />CONTAINERS
<br />6.2, PGII
<br />TFJ.5"1 - 90 041 Ut) (13ira) 112 cu ft
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2.PGI1 g
<br />Fs�I :s7 Crai xtah (i3io) (4,9 it)
<br />"
<br />) t/
<br />Cu
<br />I=
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />O
<br />6.2. 131311
<br />'VB14 44 f-44 Tuh(rig"va) (5,9 4--u ft)
<br />Cu
<br />Cr4
<br />UN3291, Re ulated Medical Waste. n.o.s.,
<br />6,2, PGII g
<br />6S X ?t) [3zt1 Puly(d.i-rs} (? 3 <„1x •t"t)
<br />Cu
<br />W
<br />UN3291, Regulated Medical Waste,
<br />6.2, PGII
<br />Pti.lS 7..0 uta. TO) {J?aCTt) {?... 1 01.l Et:)
<br />Cu
<br />IZ
<br />Lrj
<br />U0291, Regulated Medical Waste, n.o.s.,
<br />6.2. PGII
<br />-ry.(: - 2O c4e1 Tut, {ch,etni,,) (2.'r eki Tr-)
<br />Cu
<br />UN3291, Regulated Medical W3slo, n.o.s.,
<br />6.2, PGII
<br />Cu
<br />1.1=91, Regulated Medical Wnle, n.o.s.,
<br />6.2. PGII
<br />Cu
<br />C
<br />3. Generator's Certllleation: `1 hereby declare that the contents of this consignment are fully and accurately TOTALS ` / e, .�• ...:
<br />Cu
<br />described above by the proper Shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />Ore In all respects In proper condltlon for transport according to applicable International and national governmental regulations”
<br />'~
<br />Printed/typed Name s;;•? l...e r f'!' i` ' r: / i, f"! r•.,.: Signature 'J�"'—'�-�.--. Date C'
<br />c
<br />4. TRANSPORTER 1 ADDRESS: r Phone #:
<br />;SCrh li_ o/i`�.cb, ll,i_ . +I'I!A• 3 x-�% a Tlti;•cst qh ah1T-I1IEr{TI*ppllCable Permit Numbers:
<br />}
<br />et
<br />4,135 W. Sw1.tP„ St.
<br />2 IL
<br />a Q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. G
<br />~
<br />/ ✓ i rj
<br />�`
<br />Printrrype Name `� Signature Date
<br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone:
<br />N
<br />ts�
<br />AppllCable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />ul
<br />F—
<br />PrinV'Fype Name Signature Dale
<br />G. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />uo a
<br />Applicable Permit Numbers:
<br />ut
<br />1
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION; Recelp► of medical waste as described above.
<br />CC -
<br />PrinUType• Name Signature Dale
<br />7. DISCREPANCY INDICATION
<br />`, Transferred containers, cu ft to : North ;31 lake, UT
<br />--- _ .
<br />?.
<br />BA. bealgnated Fdplllty: ❑ 013. Alternate Facility: 8C. Alternate Facility, F -18D. Alternate Facility:
<br />:aterlcyci6, Inc,. atericyciu, Inc, SGericycle, Ino. Sterlr_vCle, Inc.
<br />q
<br />41 ?v \6J. aMAft .12,1• 30 With 1100 W-�;t 30:42 San Ahtoh16 SiNiA 3775 E. 2fittl St,
<br />U.
<br />Prasna.CA 9aTI" North .salt Leke. UT 84064 Hay"ard, CA 946,,44 VernQrl, CA 9008
<br />Z77
<br />i iii (8t11) Stet-t�v?ir (5i0) 562-21%7 (323) 362 --moil
<br />UJ
<br />I'SiCJ '(';i2 3A -44F3 -J,&-36 fay lrf�VC>S'f t I'Jlri^,'1=26
<br />F-
<br />TREATMENT FACILITY: t certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />M ag
<br />received the above indicated wastes In accordance with the requirement outlined In that authorization.
<br />PrInVType Name Signature Dale
<br />Received Time Sep, 28. 2012 4:14PM No. 0281
<br />LEAVE AT rF.NFPATnn
<br />
|