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.fro0* Stericycle <br />0. <br />ivir_Ln%.,mL_ vvmo or. i nP4%or%nm%m runivi vwml7r <br />IN CASE OF EMERGENCY CONTACT: CHER4 I � I-Ond).OnA-0onn 1) MANIFFA*r not i r)-nR-RTn <br />L EN 'ONNAV" 0 Z 'Ll nv:,,�; wii P ; A I ; 3 <br />i 1W <br />1. Gdfterator's:. Name, Address and TelephTne Number <br />ELMHXVi,".11 <br />i�;;940 PAA.C.1F1C' AVE <br />1 -NN' <br />.. � X'.'Z.VVL, %':A <br />CUSTOmEF4 Numweo:4 Cr 18 0. 18 <br />2A. DESCRIPTION OF WASTE 2B. <br />�I�i�1�lE��!lI���Ifl!�'l�9��6 <br />6r 6^ 1 <br />S ftOISTRATION 0 <br />3. Generator's Certification: 1 hereby I declare that the contunis of this consignment are fully end accurately TOTALS 110- <br />descrIbod above by the proper shipping name, and are classified, packaged, marked and labollorplacaided, and <br />are In all rospGcts in proper condition for transport according to applicable International and natlqnal governmental regulations" <br />4.. u 12", <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />Cu <br />Cu <br />9 Cu <br />Cu <br />Cu, <br />Pj�nt6dtiyped Narfie r'rr.."N —Signature <br />a il: 77 <br />4."FRANsPoFFER 1 ADDRESS: 4 S 5 K7 7 7 5 -7 ISA 74—F <br />t ez, r.i,e:yc` Le Fj Th:i3 .`N) -fcvj.14C01 <br />Applicable Permit Numbers: <br />413S ti. !"t <br />EE <br />EL Q TRANSPORTER CERTIFICATION: Rocuipt of medical wasle as described above. <br />.7 <br />Printo"Iype NameSignature Date <br />S. INTERMEDIATE HgNDLER 2 TRANSPORTER 2 ADDRESS: Phone 0: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medlc� Waste as deSoriNd above. <br />Print/Typu Name,' Signature Date <br />6. INTERMEDIATE HANDLIER 3 /TRANSPORTER 3 ADDRESS: Phone 6: <br />Applicable Purmit Numbers: <br />hJ <br />)2 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt otrriodlcal Waste as described above. <br />PrInt/Type Name Signature Date <br />17. DISCREPANCY INDICATION <br />Tir­Mx,-f*xMd #s t ko. : Worth, 'ah, LLk�, UT <br />UN3291, Regulated Medical Waste, ri&s.. <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 />.t,.jTREATMLNT FACILITY: i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />fv TREATMENT <br />the above indicated wastes in accordance with the requirement outlined in that authorization, <br />j Print/Type Name Signature Date <br />LFAVIF AY t�FIMPOIATrIQ <br />BT/CT 39Vd NVO N3AVHW13 �IOSGNIM ZZSOLLV60Z TS:LT ZTOZ/9T/80 <br />