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a�_" y..1, 'rN CASE OF EMERGENCY .70 CT:CHEMTRE04.800404.0064 STANDARD MANIFEST 001.10.06.SM
<br /> it r. nno�swre,r�d y,u,1: }:clutc #: i113 J t3GD-9c$--9�t3D �R�QC3�l)� '
<br /> 1,Generator's Name,Addr/e-�ss and yle lTelepphone Number
<br /> l
<br /> � BIO/LODT MEP,ORIAL HOSPITAL
<br /> 575 SOUTH FAIRMONT DRIVE
<br /> L el.,.. .-C A
<br /> Q5 3 -i� 11 2 7g/ Q10
<br /> CUSTOMER NUrAeER _ Cr-teenAT0rt`6 RerOMMAT€ort 9
<br /> 2A.DESCRIPTION OF V6JAP.TE in. CONTAINER TYPE 2C. NO,OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,r€,o.s.,6.2, CONTAINERS
<br /> UN 3291,PG 11 DOT-SPt.35S6 inkfiS - Biosyrtamo St s 3:x&=% Cart (S9 ars ft) Cu
<br /> REGULATED MEDICAL WASTE,n.o.s..6.2,
<br /> 11613291 PGII KRB$ w DioDgztrmz Tcan:spor:t Sox (4.3 au ft) Cu
<br /> REGULATED MEDICAL WASTE„n.o.s.,6.2,
<br /> UN 3291,PG If
<br /> REGULATED MEDICAL WASTE,n,o.s.,6,2,
<br /> Cu
<br /> 'UN 3291,PG II
<br /> REGULATED MEDICAL WASTE,n.o.s.,62,
<br /> Cu
<br /> UN 3291,PG It
<br /> REGULATED MEDICAL WASTE,r1,o,s.,61,
<br /> Cu
<br /> UN 3291,PG 11
<br /> REGULATED MEDICAL WASTE,n.o.s.,6,2,
<br /> Cu
<br /> UN 3291,PG It
<br /> REGULATED MEDICAL WASTE,
<br /> CU
<br /> UN 3291,PG 11
<br /> Cu
<br /> =RX151
<br /> u
<br /> 3.Generator's Certification.'I hereby declare that the contents of ibis consignment are luny and accurately TOTALS
<br /> desoMed above by the proper&Upping namo,and are classified,packaged,marked and labelled(placarded,and
<br /> are In all respects In proper condition for transport according to applicable International and national governmental regulations'
<br /> Prime ed Name Signalure
<br /> Date �
<br /> 4,TRANSPORTER i ADDRESS: Phone yr c0cy: �., F1
<br /> Applio861Q-'W, gg N,,mt,_ .5506 '
<br /> 11675 Whits F ooh Fief
<br /> 3TERICYCLE Th.iz airs a Through 3hipmr_nt
<br /> TRANSPORTMQ9RjIri%%TAA ,cWt9)C7ftte�4WI waste as aesodbod above.
<br /> PrinVType Nam . _e ! Signature pate A' `f
<br /> S.INTERMEDIATE HANDIER 2/TRANSPORTER 2 ADDRESS: Phon :
<br /> APPI10able Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br /> PdnVType Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: t Phone d:
<br /> nn0"hln pa�if�rirmtlFt/6:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of madioal waste as described above,
<br /> Kola: WLTIP1
<br /> Pr!nUType Name Signature ACf tIlkT a. 6W9oj?.W2 .r
<br /> 7,DISCREPANCY INDICATION [J / Oi0lludi Ream,ial 11,V tt!
<br /> Transfe ed _ co
<br /> t�tainers,39-Yb cu ft to : Nodh Salt lake, [) uitRlkk t0 lfIIy2119119 7:21:45 AI{
<br /> SA.Designated Facility: eB.AlEsmata Fecl IitY:_ +����O � SC,Alternala Facility:��� l'� ;,,,,f;,,, �
<br /> 11I GG GG .II `/ m'IX(UM 1: ImRLna
<br /> Sl' 2oyoCJLL,nifdG. �Y�Avenue �Q�Vnith 1fiait ioi4' VU.tK: . 110
<br /> 53.360 CtlEi
<br /> f345 avllWe r1ve,Suite C;
<br /> San Leandro.CA 94677 Fresno.CA 93722 North Salt Lake,UT 84054
<br /> y(�6- 14)692- 11781 f 658)275-�g9 (801)936- 1555 nntir;tg Khh1, frtlr00Kf KRGS : 11u rl. bar,
<br /> fS31.TSIOST7a TSfO� NN ORTIZ hl�a5 7 rnl'PIKi kri OOADO1
<br /> C3CLAVI t] � 0" �'� '€�/rF pi r?k€i° E�(BI ir�rrg.r;il
<br /> OOgODlO R)tkl t}OriX(k RXBI liu};tt ii knit
<br /> mE;ATMENT FACILITY: I Certify that I have been authorized by the applicable state agency to aooepl untrea
<br /> ecelved the above indicated wastes In accordance with the requirement outlined In that authorization.
<br /> IrinMpe Name re L!y 17
<br /> an( I
<br /> 4�1rC4� „.� .Err:,l (1� l<iutil 1 ^; 'a„;
<br /> Irl!rtglPY ira3rWl;ki tl. Pl1Vtt:illrR,.>hi
<br /> . iillai, pl:t IW R1;0 IIEEES: 3
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