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m <br />®®� sterle Cie® IN CASE OF EMERGENCY CONTACT: C 1-800.424•SM <br />®•® A.ueu,atarN. +cam Route # t 024 — 3 CUSTOMER NO. 21132 <br />Generatar'S Natne, Address; and Telephone Number <br />ATTN: 1!1 <br />GOLDEN LIVING SYPANA - 569 <br />4545 SBELLEY CT <br />STOWMN, CA 95207- 7232 <br />(209) 477--0271 <br />IV to] jj11twi <br />liiiiiiiiiiiiiiiiiiiil <br />3. aoneraler's Caa914cat[on: 't hereby dedare Mat the contents of this r»msrpnmen[ are fu[ly end i I,FiLzi t' <br />above by the proper shgrblp nme, and are �sstlied, ed, and lebaltedipl ed, nd <br />e Ire <br />In groper oondtdon tar ports to _ Inte�Nanel and n emme toRbftl <br />1ADDRESS: <br />Stericycle, Inc. This <br />+4135 A. Swift Ave <br />I'ceen�o,CA 93722 <br />F7iCrx :T:TTSrt " i7 <br />9/2/2015 <br />:C. NO. OF <br />CONTAINERS <br />Phan# (B 3-7424 <br />86dpmettt AppBcable Parrot Numbers <br />Battler Reg$ 3400 <br />Phone N. <br />Applicable Permtt Numbare: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt atmedlcalWade as above. <br />Prlatrwe Name Signature Date <br />8. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 0: <br />Applicable Pemnt Numbers: <br />INTERMEDIATE HANDLER 1 TRANSPORtER CERTIFICATION: Receipt of redtal waste as desonbed abom. <br />PdntlType Namenalum <br />43S Date <br />nsferred eontainarTs, eu 2 to : North Sat Lake, UT <br />. s SE,' a 2 4015 <br />`MEQ T FACILITY: I certify that I have <br />d th®a / 1 i w2.q In acro <br />19L t <br />11""'W <br />authorized by <br />i with the reQt <br />.adcycle, Inc. <br />1569 Shetton Drive <br />Hollister, CA 95023 <br />(B"763-7422 <br />TS9W e3 <br />31400NN 7th Street" <br />Kansas Clty. Ka 6611 S <br />(966)763-T422 <br />_28 <br />Imble state agency to accept untreated medical wastes and that I have <br />outlined In that authorization <br />Date <br />fel <br />Cu PL <br />cuffrounNwisaft 6080856-001. GUMAtMa •nolle <br />2A. DESCRIPTION OF WASTE 2B. <br />CONTARNERTYPE <br />Ul73"lB1, Rogdolod Mockettvaele,eoe, <br />8Z. P48 <br />TBOS — 40 foal Tub (Bio) {5.3 an ft} ' <br />Ut+ledieeiwmla nee, <br />PG8 <br />82.PGN <br />T849 - 37 Gal 'Pub (Bio) (4.9 Cu ft) <br />® <br />I � Nd�Vvasla,nca, <br />T014 — 44 Gal Tub(Bio) (5.9 Cu ft) <br />WWI, Rar.4ft MOM�'. <br />T821— (B3 0} TP1S— (Path} TY15— (Ciro} 20 Gal Tub (2.7=5 <br />a 2, pal <br />W <br />W <br />1u132at. q09 <br />8.2, E�I- <br />WB31—(Bio)/W231—(Path)/WC31—{Chemo}31 Gal Tub(4.14RDE <br />8.2, PGII � ' n <br />1i113b3- (gio) jPwb3- {path} jcwb3- {Rh to) 4381 Tub (S. 70WT) <br />UJIMUReaulsledrel , n.o s , <br />L2, Pap• <br />- 9liosystems Cardboard Box (4.2 cu ft) <br />UN3181.Rej;Wea Modkel Wate,not, <br />8$ pull <br />UNW.RepWded VWkftncs. <br />"PGeI <br />3. aoneraler's Caa914cat[on: 't hereby dedare Mat the contents of this r»msrpnmen[ are fu[ly end i I,FiLzi t' <br />above by the proper shgrblp nme, and are �sstlied, ed, and lebaltedipl ed, nd <br />e Ire <br />In groper oondtdon tar ports to _ Inte�Nanel and n emme toRbftl <br />1ADDRESS: <br />Stericycle, Inc. This <br />+4135 A. Swift Ave <br />I'ceen�o,CA 93722 <br />F7iCrx :T:TTSrt " i7 <br />9/2/2015 <br />:C. NO. OF <br />CONTAINERS <br />Phan# (B 3-7424 <br />86dpmettt AppBcable Parrot Numbers <br />Battler Reg$ 3400 <br />Phone N. <br />Applicable Permtt Numbare: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt atmedlcalWade as above. <br />Prlatrwe Name Signature Date <br />8. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 0: <br />Applicable Pemnt Numbers: <br />INTERMEDIATE HANDLER 1 TRANSPORtER CERTIFICATION: Receipt of redtal waste as desonbed abom. <br />PdntlType Namenalum <br />43S Date <br />nsferred eontainarTs, eu 2 to : North Sat Lake, UT <br />. s SE,' a 2 4015 <br />`MEQ T FACILITY: I certify that I have <br />d th®a / 1 i w2.q In acro <br />19L t <br />11""'W <br />authorized by <br />i with the reQt <br />.adcycle, Inc. <br />1569 Shetton Drive <br />Hollister, CA 95023 <br />(B"763-7422 <br />TS9W e3 <br />31400NN 7th Street" <br />Kansas Clty. Ka 6611 S <br />(966)763-T422 <br />_28 <br />Imble state agency to accept untreated medical wastes and that I have <br />outlined In that authorization <br />Date <br />fel <br />Cu PL <br />