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Steric cle' IN CASE OF EMEEtGENCY
<br /> �® NTACT:CHEMTREC 1-800-424-9300 1-10-06-STDNRM -FVK101
<br /> rot�myr pie.rtea�a�yn��k: CUSTOME 21932
<br /> 1.Generator's Name,Address and Telephone Number >f I g
<br /> V-,t,A.q'ap
<br /> 951W-1- 6304
<br /> $2091 954—6Ki5 k> 131 1 t'_0 i 3
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., TB57 -- 90 Gaa "£iib (15i-) (1•2 cu tt) CONTAINERS
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., Ml19 ` .37 Gal. Tub (BT-") (4,1-4 �,"A t-",
<br /> 6.2,PGII
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<br /> M UN3291,Regulated Medical Waste,n.o.s., TB1 - 44 `gad. Tub(111(0 0,9
<br /> :9 Cu T, ) A -
<br /> ® 6.2,PGII 6` Cu Ft.
<br /> QUN3291,Regulated Medical Waste,n.o.s., TE171, r
<br /> 6.2,PGII " Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s., TE15 Gal Tuot a (7° a..c
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<br /> Z 6.2,PGII Cu Ft.
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<br /> UN3291,Regulated Medical Waste,n.o.s., T fJ15 - 20 Gal Ttk (Chem*! (2.7 CU tt:t
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
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<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII p. - Cu Ft.
<br /> Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS ® p Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are in all respects in proper cooition for transport according to applicable international and national governmental regulations° t
<br /> Printed/Typed Name '`+ ' Signature , f d ,Da 3
<br /> 4.TRANSPORTER 1 DDF{ESS
<br /> 5�erd yr le, =rr:> 't Pias :i.a a T�tr:+;ugh Shipt� rzL.. Pnone#:
<br /> r 1W-
<br /> 4135 to ca ,4 t s�7 f t: Ave'. livable Per(t�it N ber
<br /> C t1.Ler PeNgt !sof .
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<br /> i q TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. j
<br /> Print/Type Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> d
<br /> 3a¢ Applicable Permit Numbers:
<br /> :5UJ J
<br /> ?w= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> 5�
<br /> PrinUrype Name Signature Date
<br /> m 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> w Applicable Permit Numbers:
<br /> -WJ
<br /> i,a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> .F=
<br /> Sz
<br /> Print/Type Name Signature Date
<br /> 7. ISCREPANCY INDICATION NorthCU ft to Saft Lake, T
<br /> - z8A.Designated Facility: 8B.Alternate Facility: ®8C.Akemate Facir : El 8 I rna F ci ity
<br /> - Es ` Afic Inc ®=dam a Inc-Indne r e I�tc clava -, t e
<br /> J Z � 4135'W.SWIFAVE 90 N - T"t 1 0 1345 Dooibe Drive Sts C 2775 E 26TH MEET
<br /> d FR SN0,CA 53722 moRTH SALT LAKE CITY,SIT" San Leandro,CA 94677 VERNON,CA 90023
<br /> m
<br /> (A-sq)r 1121cl 1' gas- 1555 1 )562-2177 (323)362-300
<br /> U �� OS722 3A 1 T"25 `TWOS"T-2
<br /> S
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> - € eived the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> lPrint/Type Name Signature Date
<br /> «.m u,.a.eP., a •xa�oa ra_ ate' ttt
<br /> LEAVE AT GENERATOR
<br />
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