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4111106W.R Stericycle' <br />MeuuaNnv ft4d. ftd-ing HIA <br />I. Generator's Name, Address and Tek <br />A:PTNt <br />—E <br />CIA <br />IN CASE OF 11M eRGENCY CONTACT- CHEIINT"Ir-0 <br />3 I'J 1 ZN0 <br />IV] rzul%/*AL- VVMO IV I n^%0MIIM4j I7Vr111I1 114VIVIDE <br />n STANDD�,ANIFMCXI1.10.08.Wrl) <br />Th <br />Wli P;Al;);� <br />., ; <br />?,'Number <br />)9� <br />20. NO. OF 2D. VOLUME <br />CONTAINERS <br />A <br />UN3291 Regulated Madicial Waste, mo,e., <br />6.2. PH Cu <br />UN3291. RQ9UWvd Medical Waste, n.o.s., <br />62, PGII Cu <br />ou I <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALSOO- Cu I <br />described above by the proper shipping name, and are classified, packaged, marked and labelied/placaid.., and <br />are In all respects in proper condition for transport according to applicable international and national governmental regulations.', , <br />Fy I lx�d Name, <br />X -Signature Date <br />4. TRANSPORTEFTI ADDRESS: 1 Phone <br />i.:� E.: 147V 17 <br />rl i 17o Applicable Permit Numbers: <br />tL !1I <br />o. • <br />TRANSPORTER CERTIFICA"'TION: Receipt of medical waste as d2bed above, <br />ti <br />Prinl/Type Name Signature Date <br />S. INTERMJ:DIATE HANDLER 2 /YiIANSPORTER 2 ADDRESS: Phone 0: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste Re described above. <br />vnnv type Name Signature Data <br />6. INTERMEDIATE HANDLER 3 / TRANSPOR-1-r-8 3 ADDRESS: Phone li; <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION' Receipt of medical waster as described above. <br />PrlmrlYpo Name Signature Date <br />7. DISCREPANCY INDICATION <br />0 14051hSdO Lako-, UT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Alf TREATMENT FACILITY: ].certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i hav <br />"oelved the above indicated wastes in accordance with the requirement outlined in that authorization, <br />It <br />I Print/Typa Naine Signature Date <br />81/90 39Vd dVO N3AVHW-13 �JOSGNIM ZZSOLLP60Z 19:LT ZTOZ/9T/80 <br />