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•a, biencycie II&AOF EMERGENCY CONTACT.CHEMTREC I-800-424-91# owiry mnv mm rEo, uu,,,u- ,o,u
<br /> V ProtectingPeople, ed d gHak. It:.e 4: 1.22 - 14 CUSTOMER NO.21 MOTRUOMM
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN:David Canosa
<br /> FM-RAI-WEST MARCH•-STOCKTON
<br /> 3115 W MARCH Tait/
<br /> STOCKTON, CA 95219- 2372
<br /> (249) 955-7527 2/15/20.16
<br /> CUSTOMER NUMBER 6050356-UO2 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
<br /> 6.2,PGII T8G5 - 9t1 Gal Tub (Bio) (5.3 cu i t)
<br /> Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.c.s., TH49 - :37 Goal Tub (Hio) (4.9 Cu ft)6.2,PGII Cu Ft.
<br /> Cr UN3291,'Regulated Medical Waste,n-o.s., T019 -. 44 Gal Tub{Bio} (5.9 cu ft)
<br /> Q 6.2,PGII Cu Ft.
<br /> Q UN3291,Regulated Medical Waste,n.o,s„ T821-(BYO)/TPiS'(path)/TY15--(Chrmo)20 Gal Tub(2.7CUF }
<br /> lIX 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s., wR:31-(13io)/WP31-(Path)/MC31-(Chemo)31 Gal Tub(4.140
<br /> Z 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n,o.s.,
<br /> 6.2,PGII W841-(f3io)/ppid�-(t?ntb)/cwo.t-(chemo) +=•i rubf5.7curr} Cu Ft.
<br /> 6 2, PGII Regulated Medical Waste,n.o-s., K uB _ Eftasystem's Cardboard Box t4.2 cu ft)
<br /> Cu Ft.
<br /> 6U23PG11 Regulated Medical Waste,n �7.o.s., f Ili i , - -, " , l Cu Ft.
<br /> Cy Ft.
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS Cu Ft
<br /> above by the proper shipping name,and are classifi ged•marked and labelled/placarded,a
<br /> in all acts in proper condition r transp rrtaacco ' appl International and national govern cation /
<br /> P led/Typed Name ♦� `rt7�te t L7
<br /> SPORTER 1 ADDRESS: � Phone#: (866) 783-7422
<br /> W Stericycle, Inc. {yL.L.,__Thi� i� a Through S t Appllcabie Permit Numbers:
<br /> E rc
<br />
<br /> waste as described6e
<br /> ~ PrinVType Name Signature - F Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> igApplicable 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 /> is w Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> LUX
<br /> Printlrype Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br />
<br />
<br />
<br />
<br />
<br />
<br /> c
<br /> TREATMENT FACIL)T*l,d'ettify that 1 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,thatauthorization.
<br /> Print/Type Name 2 Signature Date
<br /> Translured t onta rwrs, : Cu tk!o : Nolith Sid Lab, UT
<br /> TREATMENT FACILITY
<br />
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