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Stericycle Ar OF: 1-800-424 STANDARD MANIFEST 001-10-06-STD <br /> N.t.ahg N.pl�.Red.dq Ri*: TEAR HERE ---- MDF F.0 0 81 M. <br /> 1. Generator's Name,Address and Telephone Nu <br /> SERVICE RECEIPT <br /> 1,1JAHRED PAPUEKWXI-`Al� MAJ <br /> ACCOUNT #: 6069045-016 <br /> Planned Parenthood Mar Monte <br /> %J 7 SERVICE DATE: 6/20111 9:43:49 AM E,;111 9 1 i <br /> DRIVER ID: RP1 41t}= <br /> SHIPPING DOCUMENT #: NDFROOBIEX i <br /> CUSTOMER NUMBER <br /> V TMAL COLLECTED: I <br /> 2A.DESCRIPTION OF WASTE 2B. TOTAL VOL ONE: 2,700 CU FT 2C. NO.OF 2D. VOLUME <br /> CONTAINERS <br /> UN3291.Regulated Medical Waste.n.o.s., <br /> 6-2.PGI! 0OA00CI T815 <br /> Cu <br /> UN3291,Regulated Medical Waste.n.o,s.. <br /> CU <br /> 6.2,PGII T E 0A 4 VOL <br /> SIMNrRYrCont Type) OTY Ef <br /> LJ1J3291.Regulated Medical Waste.rtos.. <br /> 6.2.PGII <br /> Fj JA Cu <br /> UN3291,Regulated Medical Waste,n o.s. T816 213 Gal Tub(Path). CT 5,? 1 2 ?00 <br /> 6.2.PGII CU <br /> UN3291,Regulated Medical Waste.n.o.s., DELIVERY DOCUMENT I PDFROuBlEX <br /> 6.2.PGII I CU <br /> I'OTAL DELIVERED ITEMS: I <br /> UN3291,Regulated Medical Waste.n o.s,. <br /> 6.2,PGII <br /> r TYPE QTY Cu <br /> UN3291,Regulated Medical Waste..9-o-s.. Cu <br /> 6.2,PGII T815 20 Gal Tub(Path), CT 5.7 [B <br /> UN3291,Regulated Medical Waste.n.o.s.. <br /> 6.2.PGII Cu <br /> DRIVER: PARRA, RENE V Cu <br /> 3.Generator's Certification:1 hereby declare that the con, FREQUENCY: Weekly TOTALS 10- Cu <br /> described above by the proper shipping name,and are clas! NEXT PICKUP: 6127/11 nd I <br /> are in all respects in proper condition for transport accordin( CUSTOMER SERVICE: ntal regulations-' <br /> Thank you for choosing Steriqcle <br /> APrinted/Typed Name -L,• Date <br /> 4.TRANSPORTER 1 ADDRESS. Phone#: (5^15)2791_,_1112i <br /> 2 i r4fti1)t Applicable Permit Numbers: <br /> r <br /> 3 <br /> L <br /> C� -93 72 2 <br /> TRANSPORTER CERTIFICATION: Receipt of medical waste as 06scribed above, <br /> PrintfType Name Signature Date <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Phone#: <br /> Applicable Permit Numbers: <br /> cr <br /> OZ <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 /> a: Applicable Permit Numbers: <br /> III <br /> _j <br /> 0 <br /> z INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> 1400 Sall Lake,U <br /> 8A.Designated Facility: 8B.Alternate Facility: F 8C.Alternate Facility: <br /> r] 8D.Alternate Facility: <br /> urve <br /> inc- swv a inc,-A-&"Cave <br /> 2CIty-1 STRE"EE7 <br /> A— <br /> Entif.Ste <br /> `135 111r�,151n1c"ir-T k/E ORTH cc'11VES;T <br /> �4r. <br /> CA 9,10233 <br /> sw- C.A. 9,6 <br /> C-', IRS i 2-.- <br /> S- <br /> t555 ifi t 01562-2"7 <br /> 12 7 7 ;3231362. 1Y30 <br /> 9 5- <br /> 2A- TS111 t TS4OS f-21E <br /> S T 21 <br /> TREATMENT FACILITY. I certify that I have been authorized It, Ere 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 that authorization. <br /> Print/Type Name Signature Date <br />