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®e®o " [•p)�14It�I�G1�'"?�CANTtk�:CttEA9TREC 1.840-424-830®MEDiCAL NAD&�TpE.�TRyACK�IN�tG Fo�O�R.sMT�NUhABER
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<br /> CUSTOMER NO.2t132
<br /> 1.Generator's Name,Add
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<br /> ( �iPiRe 7Ok Hig a r
<br /> DTH QUAIL LAKE-CHATEAU HSPTL
<br /> 4 1221 ROS iE LN
<br /> STOCKTON,CA 96207-6703
<br /> (209) 177-2664 11/20/2019
<br /> CUSTOMER NUMBER 615621 OOl GENeRAmws REGISTRATION#
<br /> 2A.DESCRIPTION OFWASTE 28• CONTAINERTYPE 2C.NO.OF 20. VOLUME
<br /> UN3291,Regulated Medleal waste,nos, TM-28 Gal Tub(Bio)(3.7 au 1t) CONTAINERS
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<br /> UN3291,Regulated Medical Waste,n.as., 4f Wall U0 10101 t4m
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<br /> 311 UN3291,Regulated Medical Waste,mo,s.,
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<br /> ae 6UN3 91I Regulated b'.edical waste,n.o.s., a U
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<br /> UN3291,Regulated Medical waste,n.o.s.,
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<br /> f erator'a Certification:`I hereby declare that the contents of this consignment are fully and accurately TOTALS�' Cu Ft.
<br /> above by the proper shipping trams,and are classified,packaged,,marked and Ial�ted/placarded,and
<br /> are in I respects In proper co n for transport mording to apnliAbl ternallonall and nallonahmvKnmental regulallons° !/!
<br /> Pri tedgyped Na - u Signature �f` t
<br /> t 4.TRA PORTER 1 ADD Iric. ® Thh hro h S*mem Phone 3: p
<br /> y 4135 W. AUS APPlicaIN100 KC QQ
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<br /> o Fresno,CA 63722
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<br /> a a TRANSPORTER CERTIFICATION:Receipt of medical waste as de d
<br /> t- Pdrntlrypa Nama!—��7 Signatu Date i ~�
<br /> 5.INTERMEDIATE HANJTRANSPORTER: ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> 19
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Recelpt of med[ca1 waste as described above.
<br /> PrinttType Name Signature Date
<br /> ,, 6.INTERMEDIATE HANDLER 3!TRANSPORTER 3 ADDRESS: Phone k:
<br /> Applicable Permit Numbers:
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<br /> y tu INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> F- PdntType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> is A.oestgnatad 1188.Altem�a Feci[Ity 8C.Alternate EactlRy 80,Alternate Facility:
<br /> I�rif lal,Inc.(Autcaiive)' 3tt3dcple,Inc.(Incherater) Stericycle,Inc.(Autoclave) Coverda Marlon,Inc
<br /> AX
<br /> U 135 W.SWIft Ave 90 N.FM(boro 1304 11551 Shelton E7rlve 4850 Sroaidake Road NE
<br /> Rraartn,CA 82722 North 9wA Lack.,UT 64054 Hollister,C.A98023 Brooks,OR S73105
<br /> �tMU)I S$-7472 {t3G#p3t1-1173
<br /> �„ tae�7s�-7a2z I31:1�v)3513-E199E5
<br /> Z -11 TSIOST 22 3A-448/ A-86 TSIOST-83 Perrn>t#364
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<br /> Lu $g TREATMENT FgqC�I ,t i11 I certity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> 1— received tti�'aboiie• xated wastes in accordance with the requirement outlined In that authorization.
<br /> .11 Printrrype Name , Signature Date
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<br /> � .ry {:Y 'Yrmt tm*4 containers, CU R to :tit.Sak Lake, UT
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<br /> ORIGINAL
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