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000 Stericyde'
<br />I. Generator's Name, Address and Tel(
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<br />IN CASE OF EMERGENCY CONTACT. CHEV"`010n "
<br />ZN0 'ONNAV
<br />Number
<br />1101121JIUAL j WAb I t I MAUKINU FORM N11.1111115E
<br />6106
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<br />CusrromEA NumpeR 6 018 5 4 -- Q, 0 1 GENERATOR -a RgoisTRATioN
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<br />2A. DESCAIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3201 Regulated Medical Waste. ri.u.s.,CONTAINERS
<br />6.2. PG11
<br />90 ,_::al�Iliaka
<br />i".1jaet tAppliGable Permit Numbers:
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<br />UN3291, Regulated Medical Waste, n,o,s..
<br />T- 6, i '9 37 Git TLI,
<br />per. Z
<br />TRANSPORTS CIFICATTPN:' Re eipt of medical waste as described6;�.
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<br />6.2, PQlI
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<br />1.10291, Regulated Medical Waste, r,o.s.,•
<br />6.2, PGJ
<br />1-6 - 44 Tj;t(bA1.0!1 C -o I't!t
<br />1.�,
<br />Date
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<br />UN2291 Regulated Medical Waste, n,o,s ..
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<br />6,2 , PGII
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<br />UN3291 Regulated Medical Waste, fi.o.s.,
<br />6.2, PGli
<br />.0;&*1 TV.1h, �Fat'hi ;*Z.? clu 1:r.I
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described
<br />above.
<br />Uj
<br />Print/Type Name Signature
<br />Date
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<br />UNS291Aegulalm Medical Waste, r.o.s.
<br />6.2, PGJI
<br />5 Gai'l 1�1vko
<br />Applicable Permit Nunibors;
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<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />Printflypo Name Signature
<br />Data
<br />6.2, PGII
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<br />UN3291, Regulated imedlui wabia, nx.s.,
<br />6.2, PQd
<br />S. Generator's Certiltication: "I hereby cleclarti that the contents of this coneignmeni are fully and accurately TOTALS 01 Cu I
<br />described above by the propor shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />a
<br />are In all respects in proper condition for transport according to applicable Inlernational and national governmental replatione.",
<br />x,Arintq�/Ty pod Name Si n --r-
<br />1114LJIVAI It -III
<br />cont ainem.-
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />_received the above indicated wastes in accordance with the requirement outlined in that authorization,
<br />.ntrrype Name Signature Date
<br />1.
<br />LEAVE JflT FbFFJVlR1kTn1;1
<br />8T/V0 39Vd dVO N3AVHH-13 WSGNIM ZZSOLLV60Z
<br />TS:LT ZTOZ/9T/80
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