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20 tie+tb yc9J-°32 MI�1'O9A� 1. KNG FORM NUME <br />• ® IN CgSE OF EMEFiGEyCY CON7gC7; CHEMTREC 1.80 9300 STANDARD MANIFEST 001.10.06 -STD <br />pre.mtinq reopie. ReE�ai�g xox.' }1C�N W.'.: _: t I ,t -. ' <br />'"' CUSTOMER NO. 21133 G 'I(� ^• <br />1, Generator's Name, Address and Telephone Number FAD• r,�, r._hX,,i <br />tiS'I,?it`iIPEI�EcUC74Trt DFS , <br />S 7`i.n,'i=i'(? i3,, G'e% Q S� L: f - :_t •x �, 9 <br />CUSTOMER NUMBER t!1 ��"' J "1� v L • <br />2A. DESCRIPTION OF WASTE 2B, GENERATOR's REGISTRATION #CONTAINER TYPE <br />UN3291, Peguiatod Medlcal Waste, n,o.s., i < 2C, NO, OF 20, VOLUME <br />6.2, PGII TDja• S -G C,31 %,ate tt5ye; r ;.g L•,1 s r-) CONTAINERS <br />UN3291, Regulated Medical Waste, n.o,s,. TBS 9 - rq: <br />6.2, PG11L dub (£si,r, p (4, y <br />t:y <br />Ix, UN3291, Regulated Medical Waste, n.o.s„ X51; 4il v�1 'tub •'1 Cu <br />0, 6.2, PGII (�i`,) (.5, 9 r'u ft) <br />Q UN3291, Regulated Medical Waste, n.o,s,. '' �� - �r° �a1.. s �;.> t y ar , Z? Cu <br />a 6.2, PGII <br />W UN3291, Regulated Medical Waste, n.o.s., P�1� ;_lit t a3, Tub (P�t th) �?. 1 %u gfi• CU <br />LLI <br />� 6.2, PG 11 j <br />UN3291, Regulated Medical Waste, n.o.s., z <br />6.2,PGII 1Y15 24 9e,1 T11h fCbstn(.) (i.7 :a ft't Cu <br />UN3291, Regulated Medical Waste, n,o.s.,E�i..•xyrsr_rvta L:at'dbnatcti fox ) c u xtl Cu <br />6,2, PGII {� <br />UN3291, Regulated Medical Waste, n,o.s., Cu <br />6.2, PGII <br />PY:arlar,ca`t11:'.d.c�,1 t��.sc.; Cu <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately [!fALS ` j CU <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and Cu I <br />are in all respects in proper. condition for transport according to applicable international and national governmental regulations.,, <br />Printed/Typed Name' <br />4 -TRANSPORTER 1 ADOESS: I Signature Date <br />'Phis it, a T:6'L'v�t;-Q tt Qi Tei 17sC 7d: Phone a: 1, 's u <br />- Q ��I�S 3a.. .�ta,tft: Avt;� r p• <br />t 'O Applicable Permit Numbers; <br />r: t t_'no, 937�r la a rt:' 'i 4Ij i1 <br />:U3 <br />Q TRANSPORTER CERTIFICATION: Receipt Of medical waste as described above, <br />~ PrInUType Name " <br />Signature date i <br />5. INTERMEDIATtZ HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />w <br />Phone #: i <br />cw <br />o Applicable Permit Numbers: <br />_ INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Narne Signature <br />u <br />6. INTERtviEDIATE HAND6ER 3 /TRANSPORTER 3 ADDRESS: Date <br />r ¢ Phone it: <br />a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Applicable Permit Numbers: <br />` Print/rype Name Signature <br />i. DISCREPANCY INDICATION �� Date <br />a � i1Te's3 ii3Vtis s"s, • { 7 CU fi io . %to,rFia :*�3 %fie. 11T <br />BA. Designated Facility: j 88. Alternate Faclil ; <br />t-deofc,e. Inc. ry ec. Alternate Facility! <br />- BD. Alternate Facility <br />2. 4136 11\i, BW t.A.gs, So `I FC+tt+hr? D a+s1$61 <br />Jfnc. nti <br />I Sit?riCLrCi$, <br />Fresno CA 9 37 < North Sa)" 4�;eZ., ;JT 84 I_U � y tzoltl�rrrY>mbn Qr,,te .2775 E, do€t^ St, <br />_ . { 70- b got) 93' -. 535 <br />: A 950"::- <br />.t <br />T,;/t�Tn2 <br />t�s,i� 1�.'•� "SIOST 33 <br />t <br />1EATMENT FACILITY: I Certify that I have been authori2ed by the applicable state agency to accept untreated medical wastes and that I have <br />Jceived the above indicated Wastes in accordance with the requirement outlined in that authorization. <br />LIIL�Type Name <br />Signature <br />Da le <br />`Received Time—Nov,12.-2013-11;44AM_No,0885 <br />