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• �_.. —� -• ••• � ca.,�:E-Vtl-74 12:49:46 PCT 14�00.i7A�•1'AA iNJ•-•••••,�••• �•-n....
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<br />ONO 'ON- :Z .-Z106—'til'nd a�uil paAIa°a�
<br />tLIICAL WAS1r IH,,, -v G tUHM NUMBER
<br />®® ®® Sterieye le' ASE OF EMERGENCY CONTACT, CM&MEC 1400-421VJ ��� AuruGE ' Oet-lPobsTp
<br />s cum+' CUSTOMER NO, 21132 M RK
<br />t. Generator's Name, Address and Telephone Number -
<br />ATTN: 11111 111M I I I I If I
<br />IaKWMD VALLEY GARDEN
<br />1517 KNICKBOCIKER DRIVE
<br />STCCFM14, CA 95210- 3119
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone e;
<br />x Applicable Permit Numbers:
<br />Z INTERMEDIATE HANDLER / TRANSPORTEFT CERTIFICATION: Receipt of modicalwaste as desdrI aAOv11a, 95
<br />z
<br />— Printrrypo Name SIgnalwo Date
<br />CUSTOMER Nutimen _ GPxmAtws REQWWAnat
<br />ou A to : North Sad Lake, UT
<br />2A. DESCRIPTION OF WASTE x®. C WHAINER TYPE
<br />2C. NO -OF
<br />20, VOLUME
<br />aC. Ahamato Faslfky;
<br />UN3291. Regulated Medipt Waste, ma&.,
<br />CONTAINERS
<br />fe Inc -Autodlm
<br />stidoiclie, IM Indneragon
<br />6.2, PGII
<br />InC-AUIl0CWe
<br />Cu FL
<br />4136 W. SWIFT AVE
<br />UV329I, Regulated M241W waste, n.o.s.,
<br />1346 Dth o SW C
<br />a�
<br />tie. PGII T849 — 37 Gall, Tub (Bio) (4.9 cu t1~)
<br />�
<br />T ' � Cu Ft.
<br />Q
<br />UN3291i Regulated Medical Waste, nm.s.,
<br />(SSS) 276 -1121
<br />(Gal) 935 - 1655
<br />O
<br />TBL4 - 44 Gal. TubtRi0) (3.9 Cu ttc)
<br />WHSWcy
<br />pDA
<br />it
<br />Cu FL
<br />~
<br />UI. ReguWtcd Medical Waste, n,o,s., T'821 - 20 Gal Tub (Bi.o) (2.7 cu -ft)
<br />7S/Ob`T 28
<br />medical wastes and that I have
<br />@
<br />Q
<br />Cu Ft.
<br />W
<br />UN3291, Reautated Medical Waste, a.a.s.,
<br />OCT 31 ZU11
<br />IZ
<br />6.2.PGII 4815 — 20 Gal 'Pub (pant) (2.7 cu Pt)
<br />P��, t/rype Nemo Slgnaturo
<br />Cu FI.
<br />0r
<br />UN3291, Regulated Medical Waste, mo,s.,
<br />b.2, PC,11 TY15 - 20 Oe ub Chrsao 2.9 cu Et
<br />Cu Ft,
<br />UN3291, Regulated Medical Waste, n,o,s„
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Reautaled Medical route. n.0.5,
<br />6.2, PGII
<br />Cu Ft.
<br />Ilit Gila
<br />El -
<br />3. Genorator'a Cenificattan: *I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />' - Cu Fl.
<br />I
<br />de$Crlbed above by the proper shipping name, and are classified, packaged, marked and lapelleftlacarded, end
<br />are In all respects In proper condtlon for transpen according to applicable internatlonal and national gwem ental regulations"
<br />I. Oa x)12
<br />x
<br />Printedrryped Name r7 ,Vt Signal d.
<br />4. TRANSPORTER f ADDRESS:
<br />Data
<br />Phone
<br />5terIcycler Inc.559)275-1121
<br />Thin in a sigh hlptnent
<br />Applloa a Permit Nunusors:
<br />4135 West Swif t Ave.
<br />Battler Reg# 3900
<br />Q2
<br />Frssno,Ca 93722
<br />a
<br />TRANSPORTER Receipt of medical waste as described above.
<br />r
<br />!CCEERIIFICApTIION:
<br />42ft7 ?Gl/12"7
<br />Prlf*Typo Marne _. r' V r t- Stgnt►ttrro
<br />Dat®
<br />S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS;
<br />Phone o:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Racelpt of medical waste as dossribed above.
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone e;
<br />x Applicable Permit Numbers:
<br />Z INTERMEDIATE HANDLER / TRANSPORTEFT CERTIFICATION: Receipt of modicalwaste as desdrI aAOv11a, 95
<br />z
<br />— Printrrypo Name SIgnalwo Date
<br />OVS d Z6£8 MO? << WL �L-80-zLOZ
<br />TMns%md - mlltahwm,
<br />GA, Designatod Fnelllty: 00. Altenwte Faclity:
<br />ou A to : North Sad Lake, UT
<br />aC. Ahamato Faslfky;
<br />LJ 80. Ahvvnata Faalnty:
<br />fe Inc -Autodlm
<br />stidoiclie, IM Indneragon
<br />SWWde Inc•A
<br />InC-AUIl0CWe
<br />4136 W. SWIFT AVE
<br />so N 00 VIEW
<br />1346 Dth o SW C
<br />2776 STREET
<br />FRESNO.CA 93722
<br />N SALT LAKE CITY, UT
<br />SW Le�adro, CA 94577
<br />VERNON, CA RM3
<br />(SSS) 276 -1121
<br />(Gal) 935 - 1655
<br />(5 10) 6'82 - 2177
<br />(3==-3=
<br />WHSWcy
<br />pDA
<br />it
<br />TW 2
<br />ANNE ORT112.
<br />TREATMENT FACILITY: I certify that
<br />-448-JA-36
<br />I have been authorized by the applicable
<br />1 IrTSAjST25
<br />state agency to accept untreated
<br />7S/Ob`T 28
<br />medical wastes and that I have
<br />@
<br />received the above Indicated wastes In accordance with the requirement outlined In that authorization.
<br />j
<br />OCT 31 ZU11
<br />P��, t/rype Nemo Slgnaturo
<br />onto
<br />OVS d Z6£8 MO? << WL �L-80-zLOZ
<br />
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