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®®• StericyclIe' IN <br />` • ® I4 -W4169 Pigplc Rududhw Risk' <br />I. Generator's Name, Address and Tel€ <br />OF EMERGENCY CONTACT: CHEP"'''orrr ! en1-4ee <br />t: -4. x+'i'I;n -. 3 r6ZZ0 °NNWd <br />Number <br />m r -U .A6. YYAO I M 1 MAVIN11"Aa t'VMM IVumtoC <br />ATCNnn AMAAnPPAT iuN_, n_na.@ti'n <br />6106 Ll Th V,.. III Il Pan!;0;d <br />I <br />20. NO, OF 12D. VOLUME <br />CONTAINERS <br />Cu <br />cu8romrifl NUMBER 6 0 164',�id;� �r :k •••; ,�,, "� <br />it <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 /> <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 />TREATMENT FACILITY: I eertlfy that I have been authorized by the applicable statr agency to accept untreated medical wastes and that I have <br />= -eived the above indicated wastes in accordance with the requirement outlined in lthat a3uthoriaation, <br />I <br />PrinUrypo Narne Signature Date <br />FAVI= 8'1". O:VCNI�RTIOE u CAI w <br />8T/ZT 3Jdd ddO N3AVHW13 NOSQNIM ZZ90LLVGOZ TS:LT ZTOZ/9T/80 <br />