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<br /> y - CUSTOKER M 111132 MIj�M l.lIUMAiN 1 ,
<br /> 1.Generator's Name,Address and Telephone Number
<br /> At-IERI4R
<br /> t N RED CF035f=.T(;i-:K-I
<br /> !$IJN W•Aiil1V4(-r.LN i121,'ilil
<br /> (,200 6,14-5035
<br /> h 46763-001
<br /> CUSTOMER NUMBER 6146763-001 REGISTRATION I{
<br /> 2A.DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C,NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., Ti�14-(�:i:.`; 7F'1"—'P +E�-o i 14-0nvincrate)—411 ;sol 4`Z �utJii) Cu A
<br /> 62,PGli
<br /> 623 9 I Regulated Medical Waste,n.o.s., T[3s (� 0 ��� t 5 (P-k6�1 Ty 1t-(Chsrrlo),_.._. �{} 0-'z,' Tub(i C,, J Cu FI
<br /> UN3291.Regulated Medical Waste,n.o.s., �it3Ttati-!Indrrerate37 Gal Tu (d-9 "Ltf?.;
<br /> 6.2,PGII -` L.� Cu FI
<br /> = UN3291 Regulated Medical Waste,n.os., 1'V (l'harT(i) _ _.�13 t=$!.TU (6.7C:uf Cu R
<br /> 6.2,PGII
<br /> 6 2, PGII Regulated Medical Waste,n.o.s.. KF, ) d e-ox (r .3rd cuft.) Cu F,
<br /> s UN3291 Regulated Medical Waste,n.o.s
<br /> 6.2,PGli Cu F'
<br /> UN3291,Regulated Medical Waste,n.o.s., Cu S
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste•ao.s..
<br /> ('u F
<br /> 6.2.PGII
<br /> UN3291,Regulated Medical Waste,n.o.s„
<br /> CuF
<br /> 62,PGII _
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS ► j I Cu F
<br /> described above by the proper shipping name,and are daul ied,packaged.marked and labeuedlpl8carded.and
<br /> are in all respects in proper r n for transpod-according 1,0.aipplk W IMematiceaal and national governmental regulations."
<br /> Priated(T Ped Name J. Ia.r' t✓ _ J � L� lL.•• Signature Date -
<br /> 4.TRANSPORTER 1 ADDRESS: Phone k4 m)
<br /> SierLYGIC,1nc. � This 1� a Through ough 5110-41ent Applicable Permit Numbers:
<br /> +- *SMS -till
<br /> 7875 R A 61-i{3t}eford Rd.
<br /> i a
<br /> Q TRANSPORTER CERTIFICATION:Receio,of medical waste as described J\ /
<br /> Prtnt/iype Name (.. -1 Signature—-- rl '- Date `i`( 2 -
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 8.
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinliType Name __ Signature Oats
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrinVType Name Signature - Date
<br /> Y.DISCREPANCY INDICATION
<br /> W; SO.Alternate Faclllty: BC.Aaernate Facility: 8D.Altamale FaclNty
<br /> IKYA ,,��,',.;JC '1e,Inc of{cineratc:-j StencYcic,irlc_.(H.ut"iave) C^tiziiia '�"ar"on: Inc
<br /> '+ Jh FZA Btidg++ , 90 N, osboro ut1 e 2 715 21)�h 3t, �vQ SrGo4�ia't.e Saar°df=
<br /> s ,cM,�n.CA 952 ilfic��'A s'�cry, .,,i � 0'94 054 Jeroor. CA 91105 r3
<br /> JAN 2 7 2022 as ;� '422
<br /> �8tie)�8
<br /> E
<br /> 3A-44' Petrr/t 'rig+
<br /> T EATME IL I ty.that i have n authorized by the applicable state agency to,accept untreated medical wastes and that I have
<br /> rebeived till�i�r in accoi lance with the requirement outlined in that authorization.
<br /> Print/Type Name _ - -- Signature
<br /> TAF ATMENT FACILITY
<br />
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