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cc <br />Q <br />Ir <br />W <br />z <br />W <br />_..._�—.. „. , .. <VIM -00-94 92:_-2:0a PQ -r <br />•100097,Q0,S.A <br />' a�F i_JI..W.w..IMr..e••;..sA...l..2 <br />o20ZZ0 'IN .-Wa®tcLwAsrEYgAcceNG faaNUMBER <br />$ASE_0F­EMERG­ENC_V C-O—NTA—CT—:CMEMfREC 180042&44 <br />STANWD MANIFESTpg1-tgd9.51b <br />Route ti: 301 - .11 CUSTOMER Na 21132 MDF"RO0$VC5 <br />r, uuneraTors Name, AOCress ana isiepnone Numper <br />ATTN: <br />: <br />KINDRED VALLEY GARDEN <br />1511 "ICRBOCRF.R MUVE <br />S'POCR MV, CA 95210- 3119 <br />cuMMERNurmg° 6064005-002 <br />2A. DMRt871aN op wASTE 2B. <br />UN3291 R ulated Medit:altArasta <br />111111111111111111 M11111 11111 P1111 I I <br />957-4539 <br />(iXXMAMW81499WRATIM ti <br />6,2_PGII - n.o.s., TBS7 - 90 Gal Tub (trio) (12 cu tt) <br />UN3291Kwulated Medical waste, n,as., TB49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />0.2, P61i <br />U132911RegulMatiMedlplwasts.n.os•. T814 - 44 Gal TuiS(Bi.a) (S 9 cu tt) <br />n,o•S•, <br />mo.s., <br />UN3291, Regulated Medical waste, n.c <br />6.2, PGII <br />UN3291, Regulated Medical waste, n.c <br />6.2, PGII <br />Pbarmaceutieal va <br />T921 - 20Ga t3Lo777 —cut-0 <br />- 20 Gal Tub (Path) (2.7 `u tt) <br />1Y15 - 20 Gal Sub (Chemo) (2.7 eu W <br />3. Generators CertHttation: 11 hereby ductare that the contents of this consignmenl are fully and ac urately <br />dowribed abovo by the proper shipping name. ano are Gassirleci, packaged, mart(ed and Iabelle"IXaMed, and <br />are in all respects in proper condition for transport according to applicable International and national governmentz <br />•PrintedrTypOd Name _ __ ,,,_51(lnature <br />4. TRANSPORTER t ADDRESS; <br />` j Star I CyCle, Intim. [] Th is is a cou0. <br />4135 Nest. Swift' Ave. <br />N <br />Fresno,Ca 93722 <br />CL a TRANSPORTER CERTIFICATION' Receipt of medical waste as described above. <br />V <br />Prhxnyp®Name Signature <br />1/16/2012 <br />Dat® <br />Phoned: (559)`275-1121 <br />Shf et4tAppicable Permit Numbers: <br />Ranier Reg# 3400 <br />tsar® <br />11612. <br />T. DISCREPANCY INDICATION <br />Transfermd col tattlers, ou 8 to , Nolh Salt Lake, UT <br />BA. Deslpnatea Feslilq: 8B. AltamaM Fac11f1y 8C, AlGtneta 1`5011 y: 80. AIt,Otttet0 Facltltyt <br />SbericVde Int -Auwdave ftwlI yds Ino- Incineration Stvftvde Inc A%Aodevea Inc-Autadave <br />4135 W. SiMFTAVE SO NORTH 1 IGO V WT 1345 o On" Ste C 226TH MEET <br />W FRE�IO,CA 93722 NOR'T'H SALT Lme CITY, U San Leandro, CA 94677 VERNON. CA SM23 <br />( 659) 275 - 1121 ( tat] I) 936 - 1556 (510) 60- 2177 (329) 392- 3000 <br />LU T5/OST22 3A-448•JA-36 •T831/TWOST25 TSIOST 26 <br />DALE IME O'�r <br />JITIZa <br />TREATMENT FACILITY: 1 Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F a received the abindicated wastes In accordance with the requirement outlined in that authorization. <br />ovAR 1 g Z1f11 <br />Print/Type Nome�signature Onto <br />_ —-rplHto !ad i2.1vr20tE _ ORIGINAL - - - --- <br />O L /6 d 26£889ti602 << 2t`: � L t L -80 -Z L OZ <br />S. INTERMEDIATE HANDLER a / TRANSPORTER 2 ADDRESS: ' Phone N: <br />µWWµrr <br />�Q <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />Printrrype Name Signature Date <br />G. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Pnone d: <br />Appilcable-PermIt Numbers: <br />S <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION! Recelpt of medical waste as described above. <br />- <br />Pfintrrype Name Signature Date <br />T. DISCREPANCY INDICATION <br />Transfermd col tattlers, ou 8 to , Nolh Salt Lake, UT <br />BA. Deslpnatea Feslilq: 8B. AltamaM Fac11f1y 8C, AlGtneta 1`5011 y: 80. AIt,Otttet0 Facltltyt <br />SbericVde Int -Auwdave ftwlI yds Ino- Incineration Stvftvde Inc A%Aodevea Inc-Autadave <br />4135 W. SiMFTAVE SO NORTH 1 IGO V WT 1345 o On" Ste C 226TH MEET <br />W FRE�IO,CA 93722 NOR'T'H SALT Lme CITY, U San Leandro, CA 94677 VERNON. CA SM23 <br />( 659) 275 - 1121 ( tat] I) 936 - 1556 (510) 60- 2177 (329) 392- 3000 <br />LU T5/OST22 3A-448•JA-36 •T831/TWOST25 TSIOST 26 <br />DALE IME O'�r <br />JITIZa <br />TREATMENT FACILITY: 1 Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F a received the abindicated wastes In accordance with the requirement outlined in that authorization. <br />ovAR 1 g Z1f11 <br />Print/Type Nome�signature Onto <br />_ —-rplHto !ad i2.1vr20tE _ ORIGINAL - - - --- <br />O L /6 d 26£889ti602 << 2t`: � L t L -80 -Z L OZ <br />