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40,,e ®® Sterkyde' <br />0 hoW"ft-0-ft*-VR": <br />40 MEDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF111108tZINIftCa CT. CA MTREC 1 -8W234 -M1 @i'ro-os-SM <br />1. Generator's N&g#Mqdr@jkAjWjIephona Number <br />RAISER H <br />1721 S YOSEM17E 6-68-5321-00603 <br />HAWWA, CA 95337 <br />6018448-002 <br />CUSMUER NUMER <br />2A. DESCRIPTION OF WASTE <br />REGULATED MEDICAL WASTE, n.o, <br />UN 3291, PG it <br />REGULATED MEDICAL WASTE, n.o, <br />I REGULATED MI <br />UN 3291, PG 11 <br />Q REGULATED MI <br />M UN 3291, PG U <br />W REGULATED MI <br />Z UN 3291, PG U <br />W REGULATED MI <br />UN 3291, PG II <br />UN 3291, PG II <br />REGULATED M <br />UN 3291. PG IL <br />(809) 476-3593 2 08 <br />GENERATOR'S REGMTRAnoN R <br />?BS? - 90 tial Tub (Bio> 11.2 cu <br />3. Generator's Certification:1 hereby declare that the contents of this consignment are fully and accurately TOTALS <br />10 <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, <br />are in all respects in proper condition for transport according to applicable international and national govemm regulati <br />I IPrintedfr Name NJ 533E..e I MN -1v Signature — <br />C TRANSPORTERSUettlAftWE e, n <br />4135 Wwt Swift Ave. is a sough Shipment <br />-C a Freeno,Ca 93722 <br />a¢ TRANSPORTER CERTIFICATION: Receipt of nodical waste as described above. <br />~ Print/Type Name l .�41 � d_— Signature- <br />S. <br />ignatureS. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />N�¢7 <br />lu`'' <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFlCATIO : Receipt of medieWwaste as described above. <br />�z PrinUType Name Signature <br />G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />dao <br />pW <br />ONO <br />ff INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as deseritted shove. <br />a <br />F. Printffype Name Signature <br />T. DISCREPANCY INDICATION <br />PERMIT/SERVICES <br />2C. NO. OF 21). VOLUME <br />CONTAINERS <br />t <br />Phone N: <br />Applicable Permit Numbers: <br />Date <br />Phone <br />Applicable Permit Numbers: <br />Date <br />Phone p: <br />Applicable Permit Numbers: <br />a f <br />t1YC <br />4135 W. SWIFT AVE <br />Liffeyteftwift <br />SO NORTH 1110OVeST <br />1J C <br />9053 NORRIS AVE. <br />U ar IL�i C.B L�IrVC: <br />2775 E 20H STREET <br />FRESNO.CA 93732 <br />NORTH SALT LAKE CITY, UT <br />SUN VALLEY, CA 91332 <br />VERNON. CA 90023 <br />(669) 275 -0994(801) <br />936 -1'555 <br />(m)SM-6937 <br />1323) 362 -3000 <br />7331, <br />C3ess V Indrieration Pette 91 <br />P-6. P-11 S <br />w It <br />JACQUE WILSON <br />ul <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated <br />the above indicated wastes in accordance with the requirement outlined in that authorization. <br />medical wastes and that I have <br />received <br />JAN 13 iang <br />Print/Type Name Signature <br />Date <br />