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i • •• SteriCyCl ® IN CASE OF EMERGENCY CONTACT: CHEMTREC 1411)(142"300t '•' "'""""t' ` °`""'` Route #s 024 _ 5 CUSTOMER NO. 21132 <br />Generator's Natne, Address and Telephone <br />ATTN: <br />GOLDEN LIVING YPAN& - 569 <br />4545 SBzLLEy CT <br />STOCKTON, CA 95207- 7232 <br />12 <br />dation: 'I <br />[he pmw e <br />Woper catd <br />Num`. ��lIIIIIIi10111N1111 <br />477-027 <br />woua - Yu UAL x%W t13ROt (7.3 CR = <br />TB49 • 37 Gal. Tub (Bio) (4.9 cu tt) <br />T814 - 44 Gal. Tub (Bio) (S.9 cu tt) <br />TB21— (BIO) /TP15— (Path) /MS— (Chemo) 20 9a2 Tuft (2. <br />21831— (Bic) /W31— (Path) A C31— (Chmo) 31 Gal Tub (4. <br />WBtt3— (Bio) /BW43— (Path)/Car43— (Chemo) Sial Tub (5.7C <br />- BiosYstms Cardboard Box (4.2 ca it,) <br />declare that The contents of this consignment are fully and amuratelyTOTALS , <br />name, and are classllled, packaged, madtad and labdeftismsaded, and <br />transport sorard rin to aaoficable tntemational and nailwahxwaffimeftm ramdahan., r <br />1 ADDRESS- _j <br />Stericycle, Inc. <br />4135 w. Swift Ave <br />Vrenno,CA 93722 <br />waste as <br />Phooe#: (666)'70-'7422 <br />Applicable Permit Numbers; <br />Bauler Reg# 3400 <br />Date J"�+f" ~ <br />Phone tib <br />Appbcabla Permit Numbers <br />INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of meds al waste as desadred abom <br />Prinllilype Name Signature Date <br />IL INTERMEOLATE HANDLER 3 d TRANSPORTER 3 ADDRESS- Phone IP <br />Applicable Pam* Numbens <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnViype Meme signature Onto <br />Transfermid,�„ cartaners.co R to : NorM Salt Lob@ tff <br />SE") 16 21715 ". .... <br />IEN*ACIUff-. I redly that I have been authonzed by the <br />the above ndica was ecoorda with the requlrst <br />Name -- Ot.._...._ <br />ligde.Inc. <br />3140 N 7th SWeettify <br />Kline Cly. KS 66116 <br />(866)7837422 <br />TSIM-26 <br />uable state agency to accept untreated medical wastes and that I have <br />outlined In that authorization. <br />Date <br />Cu R <br />Cu Ft <br />Cu FL <br />Q <br />Cu <br />2A. DESCRIPTION OF WASTE <br />UNWI, ma. <br />6 PCUI <br />Unist, Repitaw Waste,acs, <br />82. P011 <br />JX <br />UN3N1; ,"A$, <br />O <br />az Imol <br />Q <br />UN329t, nos, <br />OG <br />&Z PGU <br />UN3291, nos, <br />&2. PGH <br />O <br />UM3291,11.nas, <br />62. PGH <br />fzee Wasik aas, <br />TOM <br />UM291, wash, nA a, <br />S PCH <br />(H13291, Rwbtw DAL, <br />12 <br />dation: 'I <br />[he pmw e <br />Woper catd <br />Num`. ��lIIIIIIi10111N1111 <br />477-027 <br />woua - Yu UAL x%W t13ROt (7.3 CR = <br />TB49 • 37 Gal. Tub (Bio) (4.9 cu tt) <br />T814 - 44 Gal. Tub (Bio) (S.9 cu tt) <br />TB21— (BIO) /TP15— (Path) /MS— (Chemo) 20 9a2 Tuft (2. <br />21831— (Bic) /W31— (Path) A C31— (Chmo) 31 Gal Tub (4. <br />WBtt3— (Bio) /BW43— (Path)/Car43— (Chemo) Sial Tub (5.7C <br />- BiosYstms Cardboard Box (4.2 ca it,) <br />declare that The contents of this consignment are fully and amuratelyTOTALS , <br />name, and are classllled, packaged, madtad and labdeftismsaded, and <br />transport sorard rin to aaoficable tntemational and nailwahxwaffimeftm ramdahan., r <br />1 ADDRESS- _j <br />Stericycle, Inc. <br />4135 w. Swift Ave <br />Vrenno,CA 93722 <br />waste as <br />Phooe#: (666)'70-'7422 <br />Applicable Permit Numbers; <br />Bauler Reg# 3400 <br />Date J"�+f" ~ <br />Phone tib <br />Appbcabla Permit Numbers <br />INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of meds al waste as desadred abom <br />Prinllilype Name Signature Date <br />IL INTERMEOLATE HANDLER 3 d TRANSPORTER 3 ADDRESS- Phone IP <br />Applicable Pam* Numbens <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnViype Meme signature Onto <br />Transfermid,�„ cartaners.co R to : NorM Salt Lob@ tff <br />SE") 16 21715 ". .... <br />IEN*ACIUff-. I redly that I have been authonzed by the <br />the above ndica was ecoorda with the requlrst <br />Name -- Ot.._...._ <br />ligde.Inc. <br />3140 N 7th SWeettify <br />Kline Cly. KS 66116 <br />(866)7837422 <br />TSIM-26 <br />uable state agency to accept untreated medical wastes and that I have <br />outlined In that authorization. <br />Date <br />Cu R <br />Cu Ft <br />Cu FL <br />Q <br />Cu <br />