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20V-4 3te��e ��� :32 Q44688342 P 3/3 <br />®• rrote j Y Ic. Rudvaing diff: <br />IN CASE OF EMERGENCY CONTACT. CHEMTREC 1 -Boo- •930o M CAL WASTE TRACKING FORM NUM6 <br />STANOAgQ MANIFEST OOi• 10-06•STD <br />ROtAt G 9s 301 — 12 CUSTOMER NO. 21132 <br />1. Generator S Nanta, Address and Telephone Number <br />-yip `1p���'f�E}}ww,, <br />ATTY.- <br />.- Gf MYE`. <br />1517 &W Cj,-ZRBCGI>M R DR <br />sTOCrMVr C74- 5S210-- 311 <br />GC-NERATQR's REGISTRATION # <br />A. S t: LCSIt: L: Inc.- T <br />0 4135 W. Swift A+jc, <br />(/aj �GE?EstlOs�A X372'} <br />Q TRANSPORTER CERTIFICATION: Receipt of medlcEd waste as described above. <br />W <br />Print/rype Name :•u y.,, <br />c.• Signature <br />5. INTERMt pIATE HANDLER 2 /TRANSPORTER 2 ADDRESS; <br />iW <br />14 ' <br />iz INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name <br />Signature <br />S. INTERMEDIATE HANn1 PM a iTOAnionnn— - <br />L <br />103 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wast¢ as described above, <br />Print, <br />Nam¢ <br />Signature <br />7. DISCREPANCY INDICATInN <br />Stsr}c,�, Mc_ <br />4139W, &yn Ave <br />Frftno.CA 93712 <br />Pm 275.1 i 21 <br />TS/OST22 <br />\ ` Date <br />one #; <br />Applicable Permit Numbers: <br />Fist; lee Rexo :3400 <br />Date <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />Phone #: <br />Applicable Permit Numbers: <br />Dat¢ <br />ikqmd , y inn fdne S, CU ft to : North Sal Lake, LIT <br />88. Alternate Facility:TBc-ternate Facility: <br />stalrJ , b1c.Sibeiricydr,, Inc. <br />StMton DOM <br />3� O t, S& L810, UT 8Fie, ,ae'. CA S50M <br />d iii 3 -a603i) .t <br />81). Alternate Facility: <br />r�, Inc. <br />27','5 S. 2w, St <br />lemon, CA sews <br />39TSd43i i3' P 362-4UIZQ <br />TMST -26 <br />7EATIVIENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />l;eived the above indicated wastes in accordance with the requirement outlined in that authorization. <br />PrinIfType Name I' <br />Signature <br />—'Received Time—Nov,12,-2013-11.44AM—No.0885 <br />Date '4 <br />