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0 <br />®®*Ete tNKQIl%F S COIAC7: CHENITREC 1.80847R 9388 <br />CUSTOMER NO.21132 MDFR00GUC0 <br />Generator's Name, Address and Telephone Number <br />ATT: <br />GOLDEN LIVING SYPANA — 569 <br />4545 51ELLEY CT <br />STOCKTOV, CA 95207— 7232 <br />11111111111111111111111111111111 IN I I <br />1 (209) 477-0271 8/26/2015 <br />CUMMERNuMSER 6080856-001 <br />SEericycle, Inc. <br />rsmaarowaReournt roNq <br />2A. DESCRIPTION OF WASTE <br />26. <br />CONTAINER TYPE 2C. NO. OF 213. VOLU <br />UN 1• nase <br />TBOS — 40 Gal Tub <br />(Bio) <br />(5.3 cu it) CONTAINERS <br />82 PGil <br />(866)7884422 <br />Cu t4. <br />UN320Ij ftd8h1dfloe, <br />TB49 — 37 teal flub <br />(Bio) <br />(4.9 Cil t'.t) <br />8.2, P811 <br />Cu Ft. <br />Uf320l. RepdBNdluSedleel ,nae„ <br />TB14 — 4$ Call Tub (B-0) <br />(S e 9 Cu 'it) '"'t t" <br />ratoes Certification: '1 hereby declare that the contents of this cous gnment are luo and <br />above by The proper shipping name, and are dauled, packaged marked and labibso <br />1111 pacts in p for transport a g egpRcalda hernabonal and rmhom <br />ed Nama <br />s <br />t I't 1 <br />c. <br />413S�V. SwiftAve❑ This is a <br />Eresno,CA 93722 <br />PORT RT ATl Ipt 0 kal westo os des o <br />2 ADDRESS: <br />Phone O: <br />shipment vv a — f qzd <br />W-bloPdrmdNumbom- <br />Hauler Reg# 3400 <br />Phoas fk <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pruinype Ns= Signature Date <br />e. INTERMtATE HANDLER 3ITRANSPORTER 3 ADDRESS: Phone #. <br />* Applicable Permit Numbers <br />INTERMEDIATE HANDLER I TitiNSPORTER CERTIFICATION: Receipt or medical waste as described above <br />Namaa <br />Slgnakrre Date <br />7. DISCREPANCY INDICA710N <br />Transfermd Containers, rat ft to : Noah Sal Lake, UT <br />Inc. <br />ft <br />A19 26 2015 a <br />IENT FACILITY: I certify that I <br />the above indicated Wastes in <br />B/ "Al�. E,t?�' <br />Nem <br />RA��NMOM75r--777 <br />; ,, <br />been authorized by the <br />dance with the requirer <br />Signature — <br />I <br />Icable state agency to accept untreated medical wastes and that I have <br />outlined in that authorizaton. <br />I <br />Date <br />SEericycle, Inc. <br />Steticycle, Inc. <br />1661 Shelton Drive <br />3140 N 7th Stmettify <br />Hollister. CA 95023 <br />Kansas City, KS 66118 <br />(66fi)7e3.7422 <br />(866)7884422 <br />a TSIOST 83 <br />TS(Ogl -26 <br />I <br />Icable state agency to accept untreated medical wastes and that I have <br />outlined in that authorizaton. <br />I <br />Date <br />