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® SteriC Cl • MEDIC"WASTETRACIONG FORM NUMBER <br />®: 1N CASE OF EMERGENCY CONTACT C 1.800-02¢8900 STAMMRC Got•10-10-STD <br />• + CUSTOMER NO. 21132 <br />_ - 1. t1 Q,. - '? gaenv ntti mss.-.4r�u� <br />Generator's Name, Address and Telephone Number <br />ATTH.- <br />GOTTEN 7,TUIt,IG RDANA — 569 <br />4545 Y CT <br />ST N, CA 95287— 7232 <br />-iTWii--7T:j <br />GENERATORS RESMATIQM d <br />8.2, Plitt TSA - <br />37 Gal Tub Mal 4 on ftli <br />cC UN33911 i Regulated wase, a o s„ <br />F Tf3 4 - 49 Gal Tub io S.9 <br />Q 6a �ti Regulated Medical waste, n.as„ TB21- (BIO) /TP15- (Path) ITY15- (Chemo) 20 Gal Tub (2.7CUT <br />UN32M Reit"ItW ediee a.as., <br />ttt <br />6.2, poll <br />N831-tBfo IgiE"�1-!Path Il- Ch to 6a2 5ttb 4. <br />0 t8i3291, R*1-a ed Medical Waste, n.as <br />A Phil <br />32291 Re"ted Madkat Waste, n o s.. - - <br />U, PGI <br />3. Gamiratoes CeriRcadon: "t hereby dectere that the contents of this consignment are Fully and accurawT®T <br />described above by the proper shlpping name. and are classified. packaged, marked and bbelledf0facari:14 and <br />are In all respects in proper condition tar transport according to appircable international and national govenwnental regutatwns." <br />1 ADDRE S: <br />Stet:icycle, Inc. Th" is a Through shipment <br />4135 w, Swift AVe <br />Fteano,CA 93722 <br />4CERTIFICATION: Receipt of melt el waste as described above. <br />SrgnattNe _ - ®i r•--- <br />riA I.ER <br />G'. tam of <br />CONTAINERS <br />V <br />Phones, i86t 7L3--7922 <br />Applicable hmta rs <br />Hauler: Roo 3400 <br />—I -.c ...,,. c ND 21 TRAWSPOR I En 2 ADDRESS. Phare 0. <br />� APFIII-13141 Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER C FICAI ION: Receipt of medmid waste as doscnhod above <br />Pdnt lWw Name Signature Date <br />8. <br />INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS- Phone tl: <br />Fermlt Numbers: <br />INTERMEDIATE HANDLER /TRANSPORM CERTIFICATION: Reamt ofmadicalwasteasdesenbodebovs. <br />s <br />Ix- PdnufteName <br />JUN 10 2.3151 <br />[ENT FACILITY: I certify that I have <br />the above indicated wastes in acro <br />Name la --e- . <br />cu ft is North Sak Lake. UT <br />8C. Attemate Fadifty: <br />SSS e. Inc. <br />15575 ehlton 06" <br />r, CA 95023 <br />(866)783-7422 <br />TSIM $3 <br />AD. ARamato FaNtrty. <br />Stericycle, Inc. <br />9140 N I tt Streettity <br />(8HS]783-742 66115 <br />TSMT--26 <br />authorized by the applicable state agency to accept untreated medical wastes and that I have <br />t with the requirement outlined to that authorization. <br />