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MEDICAL WASTE TRAC!?CG FORM NUMBER <br />®®®® <br />•® SteYiyceO• 2ao�qC: sSTANDARD S -10 -06 -SM <br />r <br />CUSTOMER NO. 21132 MDI; R AZN <br />1. Generator's Name AdNdress and Telephone Number <br />BTP- S69 <br />4545 MMLEY CT <br />Nr CA 95207- 7232 -`'.•- <br />y (209) 477-0271 4/8/7015 <br />CttM&URNUMBER 6080856•-001 c@lEMllaaeREaam447Boxa <br />2A. DESCRIPTION OF WASTE 2o. CONTNNER TYPE 2C. NO.OF 2D. VOLUME <br />11t }dated ste, I Waft n o S. TBOS - X10 Gari. Tub M0 (5.3 cu it} CONTAINERS Cu Ft <br />tlN � Regulated Medical Waste, n o.L, — i a (4.9 au <br />Cu FL <br />® UN 291 Regulated M Waste, n 05, � p E5.9 Cu i <br />Cu FL <br />i6.2, <br />Poll Repttlated Medical Waste, n.=, r Gu <br />W11113291 Regulated nos, W8 1— u} trip—tPath) —(Ciro 31 +Bd3 Tttb(4. C } <br />W 6.2, PGII Ft <br />sit 1 t�egt a edtrafWaste, nos. wao3-(sio) Yttti3—(path}! 2-Whemo) Gal Tub(5_7atWT} <br />CU FL <br />L 291111 Reliutaled Medical Waste. nos. L_ — Biosystpw Catedboa cd BOX (4.2 cit tt) <br />$.2, P611 ed Medical Wase, nAS. Cu <br />3. Generator's Cediftcation: *1 hereW dwirm that the contents of this consignment are ally and accurately Cu Ft. <br />described above by the proper shl%ag mune. and me class**, packaged, marked and tabelledlpftcaded, and <br />are In all respects to proper wndetton for transport a=t tg to appheable International and national governmental regulabons <br />Pct Name A'S re Date " S <br />4. TRANSPORTER 1 91Ptmne A: - <br />a� a"' 010, Inc. This is a Tlrtraugh Sta.pme <br />4735 W. Swift Ave Appiaabie Penni Number <br />a Fcestus,CA 93722 Hauler. Begg 3400 <br />m <br />CRE a NSPOR7'ERIFICATI* : R waste as aboveatMe <br />Prfnttty o Mama te t Elate <br />S. INTERMEDIATE HANDLER 2 f TRANS RTER 2 ADDRESS: Phone R <br />Applt Permit Numbers, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recdpf of medical waste as desenbed above <br />Prtntliype Name Signature Date <br />G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone R. <br />'Applicaft Permit Numbers <br />3 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />E 3 PdM/iype Name Signature Date <br />T. DISCREPANCY INDICATION Transftrmd calftltmm, txt R to : Noftb Sak Latae, UT <br />Tru �acn r rrvrw r s: t cerury alai r <br />ived the�a(}bava ktdicaied wastes In <br />tYart Marva' iC' �"L" e 91 <br />Peen aumDrizea Dy me applw,aote state a�ncy to accept untreated mescal Wastes and that I have <br />dance with the requirement outlined that auEftarizaNan. <br />n <br />