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® 'Stericycie° <br />vrmategwe.pa.R.Aimgp�k' <br />MEm AL WASTE TRACKING IbRM NUMBER <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-000-4244MG STANDARD MA MFEST QW-10.06-6TD <br />Route #.s 024 – 4 CUSTOMER NO.21132 MDFMDGHSD <br />AWN <br />{ IMAM <br />4646 <br />,x. <br />- 569 <br />11i�nwo�siin11eiivmill III <br />(309) 477-0271 <br />3. Generators Certification: 11 hereby dedam that the contents Of this Oonsignmerdlare MY and ac wnft <br />described above by the properbig name, and am cbasUled, packaged, marked and carde4 and <br />am In al re"ecip in proper oon= for tmnsW accDrdhg to apocabis international and nabonai governmental <br />t VI-r"r ;Pct ed Name �'� fe <br />4. TRANSPORTER t ADDRE6 ' Plwns a: 40001h tt3.i– f ' <br />Stec Cyicle` xAC.s is a ngh shipment <br />9130 Tri. Swift Ave ApplKaWa Permit Numbers' <br />Fceana,Ql 03?22 Hauler PAq# 3400 <br />TRANSPORTERCERTIFICATION: Rom of modWW Waste as dosaibed abouo. <br />5/27/2015 <br />0 <br />2/TRANSPORTER z S: <br />above. <br />199 <br />6. INTERMEDIJAM HANDLER 3/TRANSPORTER 3 ADDRESS: <br />19 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of me*al waste as desrnbed abolm. <br />Phone 0: <br />Applicable Permit Numbers <br />Pnone P. <br />Applicable Perms Humbert <br />Printlryps Name signature Dale <br />E <br />NA 2 l 2015 <br />TENT FAC:IL : I Certify that I have <br />the above � inedicated wastes In accoi <br />Name /a4 a.'� e <br />so. Attomate Fae01ty: <br />31140 7t111 <br />3Sftot* <br />Kansea City. KS Gal 15 <br />78=T-29 <br />authorized by the app4c:able state agency to accept untreated wastes and that I have <br />a with the retirement outlined in that authorazafion. <br />— Slgnatum Date <br />CpsroraenMUNUR 6080056-001 GeNeRAMIREWSTRAMONN <br />2A. DESCRIPTION OF WASTE 26. <br />CONTAiNE RTYPE 2C. NO. OF <br />iBft132B�1 Regulated Medical Waste, nos., <br />CONTAINERS <br />– X40 tial Tub (moo! (5.3 au Et! <br />Regulated Meckel Waste, nAm. <br />T049 – 37 Gal. Tub (RiQ (4.9 Cu it) <br />®a <br />UMM I Repifabd Ma cW Waste, ILOJ. <br />TlB14 – 44 Gal Tub o! (5.9 cu. It) <br />z PGI <br />UNW Repldabd Medica] Waste, n.o,%T01 <br />6.2, PGII <br />a – 1 a 5a tae T <br />cc <br />Lt.11 <br />UNMIl vse <br />62.P81Ren <br />1^(8sa)!�31^AahIfp31^;4fiemo}31 GU Tub(9.14 )z <br />0 <br />BU�Wjlp.l M ical Was* A-0 <br />3– (BioVVIII43– `Path} /CK63– ( a} bel T1�b (5.7attF'r) <br />Regstaied Medical Wada. n o.% <br />® - Viosystew Cardboard Box (4.2 cu tt) <br />3. Generators Certification: 11 hereby dedam that the contents Of this Oonsignmerdlare MY and ac wnft <br />described above by the properbig name, and am cbasUled, packaged, marked and carde4 and <br />am In al re"ecip in proper oon= for tmnsW accDrdhg to apocabis international and nabonai governmental <br />t VI-r"r ;Pct ed Name �'� fe <br />4. TRANSPORTER t ADDRE6 ' Plwns a: 40001h tt3.i– f ' <br />Stec Cyicle` xAC.s is a ngh shipment <br />9130 Tri. Swift Ave ApplKaWa Permit Numbers' <br />Fceana,Ql 03?22 Hauler PAq# 3400 <br />TRANSPORTERCERTIFICATION: Rom of modWW Waste as dosaibed abouo. <br />5/27/2015 <br />0 <br />2/TRANSPORTER z S: <br />above. <br />199 <br />6. INTERMEDIJAM HANDLER 3/TRANSPORTER 3 ADDRESS: <br />19 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of me*al waste as desrnbed abolm. <br />Phone 0: <br />Applicable Permit Numbers <br />Pnone P. <br />Applicable Perms Humbert <br />Printlryps Name signature Dale <br />E <br />NA 2 l 2015 <br />TENT FAC:IL : I Certify that I have <br />the above � inedicated wastes In accoi <br />Name /a4 a.'� e <br />so. Attomate Fae01ty: <br />31140 7t111 <br />3Sftot* <br />Kansea City. KS Gal 15 <br />78=T-29 <br />authorized by the app4c:able state agency to accept untreated wastes and that I have <br />a with the retirement outlined in that authorazafion. <br />— Slgnatum Date <br />