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�® ®�MEDICAL WASTE TRACKING FORM NUMBER <br />ai Stericycie' IN CASE CFE Y CONTACT: CHEMTREC 14'0042"300 STANDARD MAN*EST e01•te-®e-SI'D <br />®•® CUSTOMER NO, 21132 <br />Generator's Name, Address and Telephone!! <br />ATTN: <br />Gmi3EN LmititE HDAm - 569 <br />4545 SBELIXY CT <br />sTommu, CA 55207— 7232 <br />2A. DESCRIPTION OF W <br />_ _ _ 1, Rep MOW VOW, n <br />iiia�id■emiu'i�iii�iin�i <br />aDwAAmwo;RstaG' mmoN4 <br />3. Generahoes CerRttcattcn: `I hereby declare 00 the contemta of On cotargmnent are t and a <br />described above by the proper eh name. and we , packaged, marked <br />respects In proper condition for bars ort to huarnatronat ro <br />a <br />ed NaraZL <br />yTl/r G <br />4. POSTER i AlmRESS: <br />3tecicycle, Inc. This is a <br />4735 W. Swift: Ave <br />Fres CA 93722 <br />TRANSPORTER 'iiFl dTIOW. t)ecefpt of medkal waste as describe! adore. <br />S. INTERMEDIATE44ANDLER 2/TRANSPORTER 2 <br />N h. I <br />Gal Tub (2. <br />20. NO. OF 12!3 VOLUME a <br />CONTAINERS <br />JV <br />Ph" II((�p Date <br />AAAcebble PrlrrnTie6mlmerg. 2 <br />Hauler Reg# 3400 <br />Appbcabre Permit Naenbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recapt of seated above. <br />Prtntlfte Name fxfgnotum Date <br />& INTERMEDIATE HANDIER 3lTRANSPORTER 3 PtWe A: <br />Appfreable Permit Numbers: <br />INTE LATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />P Name sbti.b..Ea n.oe <br />� <br />r <br />been authorized by the <br />stance with the reoulrer <br />cu 2 to: NorM Sal Lake, UT <br />8a. Aftemmate Facpftyt <br />Lj 80. F-*. <br />Sbedcyde. Inc. <br />Stadcysie, Inc. <br />1661 shalton Odea <br />5140 N 7th StreetIffy <br />4 I-ldh6r. CA 95023 <br />Kwmas CRY. KS 56415 <br />(NWSS-7422 <br />VM%783-7422 <br />83 <br />7VOST--26 <br />kabte state agency to accept untreated medical wastes and that I have <br />outlined in that authonzatlon. <br />Date <br />