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1. Generator's Name, Address and Telephone Number <br />`4 177T <br />CUSTOMER NUMBER - -' -'- - <br />1 <br />GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE <br />REGULATED MEDICAL WASTE, <br />UN 3291, PG II <br />ME <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />as="`. 4 '' <br />UN 3291, PG II <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />,'.L dye7 77 '.7:1- 777, 777 -- , <br />UN 3291, PG II <br />F-1 8D. Alternate Facility: El 8E. Alternate Facility: <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />"'' "' ` 777,7 " <br />UN 3291, PG II <br />Incineration Treatment <br />REGULATED MEDICAL WASTE, n.o.s.,6.2, <br />A R a <br />UN 3291, PG II <br />Stericycle, Inc. <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />Tt3, 3 1, <br />UN 3291, PG II <br />90 North 1100 West <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />Vernon, CA 90023 <br />UN 3291, PG II <br />North Salt Lake, UT 84054 <br />REGULATED MEDICAL WASTE, n.o.s., 6.2, <br />(323) 362-3000 <br />UN 3291, PG II <br />(801) 936-1555 <br />Class V Incineration <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately ITOTALS <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />I -- <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br />Printed/Typed Name ., _ '-•) •i SignatureIX �= •'( <br />4. TRANSPORTER <br />H <br />413"!; We et a <br />CLN <br />IL Z T NSPORTER CERTIFICATION: Receipt of medical waste as described above. ' <br />Print/Type Name Signature <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />W <br />Lu <br />�FmW <br />LU <br />W. s INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />�z <br />~ Print/Type Name Signature <br />M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />w <br />WQ� r <br />®J <br />W® <br />z W = <br />