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j' <br /> mik "� � <br /> ll . , <br /> :nsrator's Name,Address and Telephone N <br /> 7. <br /> LY <br /> GENERATOR'S RIEGISTRAmON <br /> 2C. NO <br /> ', ER NUMBER .OF 20. VOLUME <br /> CONTAINERS <br /> ?a5c.q Gu Ft. <br /> ftSTE ) <br /> 26. CONTAIWER TYPE a1i Tub(ffia <br /> T Cu Ft. <br /> ii guided Medical Waste,n.os., <br /> :'X.quiated Mpdical waste,n.o.s_, 9-IT Gal 1119, (11"110) (4.9 OU <br /> Cu Ft. <br /> :-11 �Itiq�jiated Medical Waste,n O.S., <br /> Rpwiiated Medical Waste,n.o.s., Y15 GjijTUb(23CU P Cu Ft. <br /> Cu Ft. <br /> Rerelaied Medical Waste,n.os., <br /> "TuN53CUFT) <br /> R.ati'itpd Medical Waste.ri.o.S, Gall Cu Ft- <br /> Cu Ft. <br /> BpqtjI;j1Lad Medica Waste,ri.O.S, Biomlem Cardboard ftx CU III) <br /> Gu Ft. <br /> Cu Ft. <br /> Waste.n.o.s., <br /> accurately TOTALS Cu Ft. <br /> "I hereby declare that the contents of this consignment are fully and <br /> linnerator's Certification; packaged,marked and labellecl/Plararcedl and <br /> :,z�dberi above by the proper shipping name,and are classified,pack�E international and national gove regul ons' <br /> 111,111 respects in proper corrdiijon for transport according to applicable <br /> Date <br /> r <br /> .83-742 <br /> Printed/Typed Name hone 2 <br /> r,,IISPORTER 1 ADDRESS dyiow s X44 B Applicable Permit Numbers: <br /> 'v Hauler R.eq#340 <br /> f <br /> 1-J"ASPORTER CERTIFICATION:Receipt of medical waste as described above" <br /> Date <br /> Signature <br /> :—Tvocs Name Phone <br /> I-F R 1.41ZD IATE HAN DLER 2 1 TRANSPORTER 2 ADDRESS: Applicable Permit Numbers: <br /> HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Date <br /> int <br /> Signature <br /> Type Name <br /> Phone <br /> !TRANSPORTER 3 ADDRESS: Applicable Permit Numbers: <br /> ERNIEDIATE HANDLES/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Type Name Signature Date <br /> EpANGY INDICATION <br /> 8B.Alternate FSCIMY: 8C.Alternate Facility- 8D.Alternate FaC114; <br /> fiA Designated Facility: cov&Ma hmwlon'Inc <br /> Alternate OV;'M <br /> (AutoclWye) JW 81, <br /> ��dcyclt:inc.flneine"&. 4SW BMOWXkQ Rtdm" <br /> 6,3 j Sj^,j%�, n 064% 7C <br /> 51,2 <br /> AFT <br /> 7:A7,'1'JlENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> . ized <br /> ved the above indicated wastes in accordance with the requirement outlined in that authorization. Date <br /> Signature <br /> 0:0, <br /> 1� I � <br /> kint7vi-Name <br /> -it <br /> -T <br /> it to sak Lake,U <br /> LEAVE AT GENERATOR <br />