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J <br />SteriCycWE OF EMERGENCY t <br />1. Generator's Name, Address and Telephone Number <br />`7 <br />FK N. 0AL.1FORNwS*i'Jt;i; ON <br />?350 N CALIFORNLA 5`T" <br />t;'i'E1vit't'gl'. <br />(,A 962041- :1Cti <br />STANDARD MANIFEST 001.10.08 -STD <br />um <br />.CR 'A Kms, ?§ " <br />CUSTOMER NUMBER 60'j <br />81 tf' s 170"' r GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 2B, CONTAINER TYPE 2C. NO. OF 20. VOLUME <br />UN3291. Regulated Medical Waste. n.o.s CONTAI ERS <br />., ,. <br />6.2. PGII If, 34 - 28 Gi ,j !'iii] 11'6'r 13.1 rat fl) � Cu Ft <br />2GIRegulated Medical Waste, n.o.s. <br />6 <br />, PI T � ; 9 - 3 � GA <br />Tijb Pilo (4 0 cal fly <br />Cu Ft <br />6.23 PGII Regulated Medical Waste. n.o.s., JB 14 _ 44 Gal Tub(blo) (6.0 ou it) Cu Ft. <br />UN362. PGII 91Regulated Medical waste, n.o.s., TTS®i t _, )°- 5wt s'TY 112U Cyai Tub 2.'lGl i="t <br />...,� ..i 1 I r,. 9:1 <br />Cu Ft, <br />UN3291, Regulated Medical Waste. n.o.s., <br />6.2, PG11 W.1434 ?i�j,° )4.•..; ff' =- ? tial fUb 5.ICUFTt Cu Ft. <br />UN3291. Regulated Medical Waste. n.o.s., <br />6.2. PGII KR - Birl lents rdboard Box (4.3 cu ft) Cu PC <br />UN3291, Regulated Medical Waste, n.o.s.. <br />6.2, PGII Cu F <br />UN3291, Regulated Medical Waste n.o.s. <br />6.2, PGII JA <br />3. Generator's Cerfification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS <br />described ,above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are to all respects in proper condition for transport according to applicable international and national governmental regulations" <br />/\ Priratedrryped Nam® Signature <br />4 .TRANSPORTER 1 ADDRESS: <br />r+..3 T iris Is �; i ! iro°..i is Sr* txpttion <br />fi <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print(r a Name ' <br />YP . ' �. i �' `i. ,` Signature , <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printrfype Name <br />Signature <br />Date— <br />Phone "1ue,8)"34422 <br />Applica Permit Numbers: <br />i iaular Reg# UOO <br />Date ' <br />Phone #: ' <br />Applicable Permit Numbers: <br />Date <br />G. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: <br />3 cc Applicable Permit Numbers: <br />7 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />.x <br />Print/Type Name Signature Date <br />tA. Doet9natod Facigty: <br />�. <br />U 88 Alternato Facility: <br />❑ 8C. Altemato Facility: <br />80. Altemate Facility: <br />Alm` <br />){yy//.�� {{yy�t## gt# <br />ilke. d'WUd Oa-.ltj <br />., <br />ry ¢ ]�y <br />•Nil t41ts..a Incinerate <br />Nye ij #iytk R �p f ; p9y �st+y� <br />Vi "�Ti$�.++; `� R�11r. +`,W {0.�"LRtir7 :' <br />4 �y� �t,/�y� gN /�y1p [yµp�@ <br />1. ovants Wrion. We IIiMi�si/ate <br />\il�s <br />4135 A Isf� tme <br />yn�,�y q�} <br />4 � Ei c ro �rn <br />11451 Zbc tion Itve <br />0350 Rrootifoke RUStj NE <br />Pi asria, CA 13712 <br />bst 5 % I. Ise . t! PO 0% <br />tic s't a, A Sbt'2� <br />Lroc Ks OR` .7306 <br />t886�3-7#2 <br />!OST-22 <br />{xlcii <br />^�,�0i !A- lta % <br />y45G}?T3- -J <br />it6 <br />$19 <br />FieffnitT�3 <br />P71-1EATMENT <br />FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />eived the above indicated wastes in accordance with the requirement outlined in that authorization, <br />Print/Type Name Signature <br />Date <br />CU fl to : Brooks, OR <br />1f �1r tta, c �ltt>t <br />r� 1 its NSal Lake, UT <br />t: <br />