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fyny?7 <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 /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <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 />