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'Ge
<br /> a .Geherator's Na t3 Addr ss&
<br /> d TIn hone Number -'•
<br /> t A0Now
<br /> 13-TGILOD-T MEMORIAL NdlPTTAL
<br /> 9'75 SOUTH F'AIRMONT DRIVE
<br /> L,C�DI . GA 9,9240-
<br /> .......... ... ......._... . .(.2�� 33.9-.... 411
<br /> CUSTOMEANUMaeR 60890,77-002
<br /> 2A.DESCRIPTION OF WASTE 263. GENERATOR•&REOISTRAVON N
<br /> Co—A
<br /> UN3291 REpufatedMQ3r03ifNi3td,168 ., Ki1tt5 - B.ioSp;texz $haxpz Tx-alrisL59 eu fw COERS
<br /> RC&:rt NT 2b•
<br /> 6.2,PGII 2C, NO.OF VQl.tlMtw
<br /> 1,1102
<br /> 02 Pa1GII RegulatedMedlealWasle,n.o.s„ TiiaS���tesnb Tranwport Sox 9. CU
<br /> 6.21,
<br /> 623231,
<br /> 6..2,M11Repulatatl Medical Waste,n.os.,
<br /> i
<br /> UN3291 Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGll
<br /> UN3291 Regulated Medical Waste,n.o.s.,
<br /> 6.2,pa[I
<br /> •E
<br /> UN3291Regulated Medical Waste,n.O.s.,
<br /> 6.2,Pali
<br /> E
<br /> 6.23291.Regulated
<br /> 6.2,PGII Medical Waste,n.o.s_,
<br /> t
<br /> 6.2,at Regulated Medical Waste,n.o.s.,
<br /> IttibT
<br /> 3.Qenerator's Certlficatlon."I here
<br /> described above deCfare that the contents Of this OOnsignment are fully and accurately TOTALS � �
<br /> are In era b1'f0 Proper shipping name,and are clasglfled,packaged,marked and labelfeWpraoarded,
<br /> sPOWS in proper c Mo r transpoda000r m to C
<br /> � g apgftca6le international and national govern taE rpg tions" /
<br /> Prinfad/TYped Name �/�/• � .
<br /> d,TRANSPORTER 1 ADDRESS; Signature Date
<br /> J..10" White Rock Ild � Phone( 16) 985 -- 5506
<br /> 5TE,RICY1ZLE lR,. '^h i T� i- T1:rough ,yhipmLnt APPllcable Permit Numbers:
<br /> TRANSPORTEW19h -AW64A CA 9517Q2
<br /> ecelpI of matt s1e as describod a
<br /> Prfntftype Name r�+r •I �lt � hl
<br /> S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS; Signature Data tJ .
<br /> Phone it:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Rooelpt Of medicat waste as described about.
<br /> PrinvType Name
<br /> Signature
<br /> 6.IN'CERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRJw5S: ^" w
<br /> t ,
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Reoalpt Of medical Waste as described above.
<br /> St�I1VICE 11L001 ,u
<br /> Printliypa Name
<br /> SlgriatuACCT➢w 1: 6089077-002
<br /> 7.DISCREPANCY INDICATION ro D1D71.odi *wl lit Hospital
<br /> Tranafe d R C� ?/� VINICt' DAIS• 5121110 7:15:25 AN
<br /> t;ors�ainars, .!%�V(C� cu ft to . tVartl-i batt take, DRItK;It to: al8A.DesignatedFaoNity: 8131 Altemate Facility: ' �lilfn1N(iD0(.1k1 l If;
<br /> Z'J DOC.Attempts Facitlly: / tt(k0{19t
<br /> 1346 DoolittleGt E,INC. STERICYCL.E.1fJC. !L_,� rI V tOfA[. M.tEEIED; 25
<br /> 1a4S�aDrive.'Suite G �31�ti W.SvvlftAvenue STi<RICYCI...Ir iIVC.
<br /> San l er3ttdrtl.GA 94577 9Q North f I GO Nest IDIAL VOL111- 216.160 CU f I
<br /> Fresno,GA 93722
<br /> {5i fit X82- i 781 S
<br /> f5591275- 0994 NOM Stitt Lake.UT 8411 ,k: Ea;r ssRf , MAD094 KR6b •.�tt it 1,:�n
<br /> �� 7'Slf j tt�AtdNE OtD Class 1 n r Io T('�I 00110 NU 16'X81 ;: ,x' :'•4
<br /> • �Tl]CI.AVEt3 wla..., !t„c�s;e,ation errn�� i'��•' •:1,.
<br /> �. �N � T i : �R:Aoiuta.illcfif
<br /> REATMENT FACILITY: I certify that I have been authorized by the applicable sts a agency o accept untrea a 01 )HRoj
<br /> :ceived the above Indicated Wastes in accordance with the requirement outlined in that authorization. r
<br /> rintlType Name (Jug”RMJ
<br /> VIA&11-4 f) ;:1WLjfk,(Conl fype) O,S, VOL
<br /> TAE TMENT FACILITY
<br />
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