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0 0 0 Stericycle' <br />.. ®• ' PIOIY(LWQ PwP1,.lad,A1V Wyk: <br />1. Generator's Name, Address and Tele <br />iru�t s:3T�;kfrak r;°:�v r.;EN:R1% <br />S'[°;C"""•k'T'F'I';�t+ u is � :b c_,;�f it -? <br />I <br />IN CASE OF E ERG NCY CONTACT: CHEIvITAFC 1.ano—�p�uA <br />�., :.� � �ZZo NNAV <br />p ne Number <br />CusTomo-A Nuanatrt R:,t r 1 P.};_� ""Lir} GENERAT0111Is REGISTRATION # <br />.•yy_vw­ -W 1 ` I nn%.r%ue•a rvnrvi lvulwooL <br />STANOV.0 MANWES-1.001-10-0e-STD <br />Z10Z 'Ll Inyk:,awll paniana� <br />I2A. DESCRIPTION OF WASTE I2B. 'CONTAINER TYPF� I2C. NO. OF 121), VOLUME <br />UN3291 Regulated Medical Waste, n.o.s„ "1'� 5 a 9if G�*i Z 6: t;t��_ I. �� ='eu et 11 CONTAINERS <br />6.2, PGII Cu <br />UI43291, RugLlatad Medical Waste, n,o.S„ +;0, 7%;", t' i,.< ; t'41 • 1r <br />pG <br />UN3291, Regulated <br />O <br />6.2, PGII <br />Cu <br />UN3291, Regulated <br />4?l <br />6.2, PGII <br />W <br />UN3291 Regulated <br />Z <br />6.2, PGII <br />arta in all respects in proper condition formansport according to applicable international and natignal governmentalr(;gul�tlons" <br />UN3291, Regulate6 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />GIP <br />•+EATMENT FACILITY: I certify that'l have been authorized by'the applicable stat) <br />agency to accept untreated medical wastes and that I have <br />,ceived the above Indicated wastes in accordance with the requirement outlined in�that <br />authorization, <br />Prinl/Type Name <br />Signature <br />Date <br />At'1r �_`ICMtIC CA Yt7Tk'1r1r <br />8T/LT 39VJ ZtIVO N3AVHW-13 �10SQNIM ZZSOLLV60Z T5:LT ZTOZ/9T/80 <br />