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Rx Date/Time JUN-17-2011 (FR1) 12:05 P. 006 <br /> 06/17/2011 FRI 12: 15 FAX � <br /> N6 7 %tencycie- IN CASE OF EMERGENCY CONTACT'pttM101tt;*4904a"=0 ....f�caIZO 0 6 90fi//0028 v <br /> ` +�rw..r.w.�.fo.: Poute 4: -033 ti X00-'1i�-9��141 <br /> t1 tt <br /> riPRC •. , _G <br /> FCi <br /> t.Cieneratar'g Name,Addre4t;and Telephone Number Il I( {Iii I <br /> jj <br /> t z <br /> ;aI4lL•QDI• iFi��OFI�I, HrJa�rT�L• <br /> 915 SZOUTH' FAM-10'-PT RUE <br /> LODI• GA 95:40 <br /> 12091 <br /> Cyst oIwEA MIJIraER i.'r K G-e•y 7« '���7 <br /> �EltErtATOnf REt'tsrn►Tlam f <br /> 24.DESCRIPTION OF WASTE 7B CCMTAIN!RTYPE <br /> 2G aro.OF ra, vuLM <br /> Fn-�-W <br /> 1,RepulAtep AltpiC3lYiySltFAN,- <br /> a. ? CORTAINETRS <br /> ti CtT•SF IiS,- K3?63 - BioSpsccn►: harp: Tlretax Cort (59 c:s ft) 1-7 <br /> E- E <br /> iAMiplYYasta•no.s,. Tran.a�rr Box (i.3 ^,u ft:) <br /> wau,21 epu4ted Me�eaf Witft.AA f, r <br /> 1HR291,iteptdiIN Mrdicm wile. <br /> 62.P&It <br /> urn t.Hepr►qu tI Mt111caI Wite,Is e.s„ I <br /> 6�.Pa <br /> UIei29tBegvbftd Me6m,Wort,n.o.s,. 1 <br /> 62.Pod <br /> ��I.�pugted Medical WasEe•n.os r <br /> 6.2,PCII <br /> 17.f EI r� <br /> V •• 1 <br /> TOTA <br /> 3.Generator's Cartifiaatton:•I hereby aectare they Me cments of INcar awm Mena are 1641Yarty 41=08"l7 ra41=08" LS ► 21-4 2-)7-5`, <br /> ate""ab"by ate'"PW sttipptng mere,and era tdassified.PtrOW00,MWked and tabetlediptacarded,amttl r <br /> r@ In ad ee9peets to pmoper I endlflpn <br /> for summon acoordinp w xoica&e bumnatiumf ord natknaI Dom namalrogoadom., j <br /> PdMildfTYP"Nome ��n 19 �r 8 nature 1?aro 5 <br /> = t.TRANSPQRTEIi I ADDRESS: <br /> Movie C <br /> ApPjbte F'eirr9t Numuers 0� <br /> 11875- White Pock � � '_ <br /> 37' R_C'fCLE 1( This a Thr_ag. <br /> TRANSPOR WEMIF Wiers:i}pr& I waft as dUW bed above• <br /> Prdtaype Name N gignarus Date <br /> 5.INMRMEWATE"ANfOLER 2 r TRANSPORTER 2 ADDRESS: Phone r: <br /> Applicable Permit ftemtoers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recsigx Ili inedicar waste as oncribod aum, <br /> Prtnt VPe Name Sigrtatura ---.,_Date <br /> S.INTERMEDIATE MANDLER 31 TRANSPORTER 3 A00AES5: Pf%M a. <br /> o: <br /> W AppficeW Paras Nuftems: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described apavo. <br /> z <br /> i <br /> tyeinOV"No" 3lgnruvre_ — Date <br /> 7.DISCREPRNCY INDIC&ON <br /> Transferred 0(%2container:, Cu it to : IVfl # & T <br /> O W oo.IQrsatlyd Fsetftry: Oe.Atte rrtele fadrflys sc."WnWAIMIM PUM 11,11 L— <br /> 0 ornru rscillty: <br /> STEFICYCLE IAIr�. STERICYCLE INC. STEF"'CU.INC' STBRI YCU.INC. <br /> 1345 Docfals CttivB.cvi;e C. W. +m i n <br /> �i 5 SvYitT AYenII ;? PI•.rtfe l t4l W?p 0 9 10 �:• Starr 4 <br /> San Leandro CA 91577 Fresno.CA 9372.=, Nor�r Sal;Lake,U P054 Yuba Ory,4A 9 59S 1 <br /> (5101582. 1131 15591 275- 0904 fSOI l ia8• i 5i5� 1.301-15 -Orr , t <br /> TREATMENT FACILITY:I cerlily that I have been authorized by the applicable slate one o accept untreated medical wastes and that I have <br /> received the above I Oared tris in aCCordance with the requirement o dirt I rizlation. <br /> owl <br /> PrintffA*Name r <br /> ''�? 5[gna�ere Dare <br /> 011 / <br /> �,c <br />