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1�6 m=wu%,mL- vv^o i c: I r.A-nan%z rwmivi riwavior-n <br />*a Stericycle, IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-234-0051 <br />I <br />i. Generator's Name, Address and Tel one Number <br />N <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />REGULATED MEDICAL WASTE, ri.o.s., 6.2, <br />yCONTAINERS <br />UN 3291, PG 11 <br />Cu F <br />REGULATED MEDICAL WASTE, ri.o.s., 6.2, <br />j <br />UN 3291, PG 11 <br />Cu F <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />n, <br />0 <br />UN 3291, PG 11 <br />�4 <br />Cu F <br />REGULATED MEDICAL WASTE, ri.os.,6.2, <br />LIN 3291, PG 11 <br />Cu F <br />LLJ <br />REGULATED MEDICAL WASTE, ri.os.,6.2, <br />Z <br />UN 3291, PG 11 <br />Cu F <br />LLJ <br />REGULATED MEDICAL WASTE, ri.os.,6.2, <br />UN 3291, PG 11 <br />Cu F <br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, <br />UN 3291, PG 11 <br />Cu F <br />REGULATED MEDICAL WASTE, ri.o.s.,6.2, <br />UN 3291, PG 11 <br />Cu F <br />Cu F <br />"I TOTALS Do- <br />3. Generator's Certification: hereby declare that the contents of this consignment are fully and accurately Cu F <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects In condition for transport according to applicable international and nation lgQvernmental regulations." <br />IV j <br />X <br />t <br />Printed/Typed Name' Signature Date <br />4. TRANSPORTER 1 ADDRESS: Phone #: <br />LU <br />Applicable Permit Numbers: <br />IX <br />< 0 <br />U)(L <br />I <br />Z <br />TRANSPORTERZERTIFIC ION: Receipt of medical waste as described.a ove./ <br />Print/Type Name Signature Date <br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #: <br />"uj <br />25 !a o: <br />Applicable Permit Numbers: <br />UJI <br />0 M C3 <br />0: Z <br />2 W 4 <br />LU= <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />P <br />;99 <br />Print/Type Name Signature Date <br />W6. <br />INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: <br />IX �-- <br />UJI Ix <br />Applicable Permit Numbers: <br />F3 uj <br />W -j <br />02 a <br />M< <br />zZ <br />UJ <br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />< <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />k <br />8A. Designated Facility: <br />88. Alternate Facility: <br />r <br />Alternate Facility: <br />8D. Alternate Facility: <br />0 8E. Alternate Facility: <br />ME <br />Autoclavable Treatment <br />Autoclavable Treatment <br />Autoclavable Treatment <br />Treatment <br />Incineration Treatment <br />Stericycle, Inc. <br />Stericycle, Inc. <br />Stericycle, Inc. <br />Stericycle, Inc. <br />LL.! 3 <br />2775 E. 26th Street <br />1345 Doolittle Drive, Suite C <br />4135 W. Swift Avenue <br />90 North 1100 West <br />2 <br />Vernon, CA 90023 <br />San Leandro, CA 94577 <br />Fresno, CA 93722 <br />North Salt Lake, UT 84054 <br />Z N E <br />W <br />(323) 362-3000 <br />(510)562 -1781 <br />(559)275 -0994 <br />(801) 936-1555 <br />Class V Incineration <br />MWTF Permit # P-1 15 <br />MWTF Permit # TS -31 <br />MWTS/OST Permit # TS/OST-22 <br />Permit #91-02 <br />MWTS Permit # P -6 <br />MWTS Permit # TS/OST-25 <br />Treatment by incinerate <br />tu <br />I KhAl-M hNI FACILITY: I Certifv <br />that I have been authorized <br />by the armlicable state aaencv <br />to accept untreat <br />