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o: sterlryCte• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-8e0424-93an <br />®°' ` °" q61•CUSTOMER NM 21132 <br />G=EN LIVING 112PAIA <br />4545 SHE T CT <br />STOOMR, <br />2A. DESCRIMON OF WASTE <br />Urg2j, Regulated Medical Waste, <br />M <br />UN �i Reptald Medical <br />Me%n.as — <br />F – 4A Cal Tub 15.2 <br />Q UM291 Regulated Medical waste, n.e.s., <br />CC &Z P611x921- (t=1 ITeSs- (path) ITYls- <br />291 Regbtated Medical Wash, n.n.s., – – <br />ul R N 1, <br />&2,t� eptaated Me waste, n o s , <br />4c <br />S. Gets Car iitcetlon: 9 hereby declare that ft contents of this consignneinl are fu <br />described above by the proper shtppfng name. and are classified, packaged, marked and Is <br />are in eft respects In proper conda[on for Vansport accc5ging to applicable knomaborml and <br />4. <br />St erioYcle, Inc. 'Pins is a <br />4735 X. Swift Ave <br />Tresi® cA 93722 <br />CERTI C/TION: Receipt a t waste as descrIbed <br />—r_-__ -,4 <br />MEDICALWASTETRACKING FARM NUMBER <br />STANOAIiO MANIFEST WI -10 -011 -STD <br />IC. MD. OF <br />CONTAINERS <br />Gal Tubt2. <br />M <br />Shilsmetct - Pehi:ffi)rZ93—�4" <br />Haulet: Reg# 3400 <br />` <br />Data. .?X- <br />S.� <br />HANDLER 2 7RANSPOIiTER 2 ADDRESS: <br />40,19 <br />04MMEDIATE HANDLER /TRANSPORTER CERTI1FICAi1ON: Rece! t of dleal waste d <br />p me as embed above <br />PdnN o Name <br />svlak- <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTERA AnnraFcc. <br />Phone R. <br />Applicable Pemut Numbers. <br />Date <br />Phone 4- <br />Apptxable Pemut Numbem <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Raelpt of medical waste as described above. <br />PAnvTww Name Signature Dam <br />E 3- <br />t7eefprtatod Fac9lty: <br />a <br />4196 W.. a AW <br />F- <br />A :a <br />Freena,CA MM <br />(5961783-7«122 <br />110"Amom" <br />F '� <br />tIf <br />r.q <br />lived 08ainam <br />I c, ft to : NotM say M, ur <br />Alternate FacOhy: <br />U BC. AMemato Fedthr. <br />0 8D. Ahamete Fadnty. <br />SEarlicycle, Inc. <br />Sboer1qde. Inc. <br />Staticycle, Inc. <br />90 N. F m Deals► <br />1651 Shftn DfNa <br />3140 N 7th Stme try <br />Aorta Sid I-alte, Ur 84OS-- <br />M 4 Hollister, CA SSM <br />KwiseeMK9 66115 <br />(%-"6)783-7422 <br />(866783-7422 <br />(SM783-7422 <br />t P" ATLL Do <br />Talwea <br />7=9r--26 <br />o tcable state agency to accept untreated medical wastes and that I have <br />cr ardance with the requirement <br />outlined In that authorization. <br />APR I <br />Date <br />1 <br />