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'TefICyCI@ —. — ..o <br /> 11-07 <br /> ® i�n..d..... .............- .-.C..U..S._TO_ME_fl__NO_..221132 OF::11lt V <br /> IS <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Rr ian Hanson <br /> sla .i 4RGICIP L <br /> 5801 141SM ST <br /> SOIrC]k 95206-- 44)Ill , 12/7:2U1� <br /> (209) 982-x+199 <br /> CUSTOMER NUMBER 6016095--002 GENERATOR'S REGISTRATION If <br /> 2CONTAINER TYPE 2C, NO.OF 2D. <br /> A.DESCRIPTION OF WASTE 2B. VOLUME <br /> CONTAINERS <br /> UN3291,Regulated Medical Waste,n o s THOS _ 40 (;.81 Tub (Sit-II0-3 cu ft? Cu <br /> 62. <br /> 2,PGII <br /> UN3291,Regulated Medical Waste.n o s, T54 9 _ T? Gal Tub (Rif") +$.4 Fu ft) Cu <br /> 62.PGII 1 <br /> CC UN3291,Regulated Medical Waste,n o s. Te14 - 44 bag Tub(Sif)) i" r"u 1t) Cu <br /> ® 6 2,PGII <br /> Q UN3291,Regulated Medical Waste.n o s, TE21 - 20 C+al Tub iBiu) (2.7 C-11 ft) Cu <br /> Cr. 6 2,PGII <br /> W UN3291,Regulated Medical Waste.nos. g81S - 20 laial TWO (Fatl') 62.7 Cu'ft) Cu <br /> Z 6 2.PGII <br /> f3J UN3291,Regulated Medical Waste n o s. Cu <br /> � s2,PGu Tlras - ala tial ruts (chi`/) t2 '� cel fr.) <br /> UN3291,Regulated Medical Waste n o s, Cu <br /> 6 2.PGII <br /> UN3291,Regulated Medical Waste n o s Cu <br /> 6 2.PGII <br /> Cu <br /> 4`I1,armarout.i%a1 b►ast8 <br /> 3.Generator's Certification:-1 hereby declare that the contents of this consignment are fully and accurately <br /> TOTALS IN, t Cu <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> are in all respects in proper condition for transport according to applicable mtetnabonal and national governmental regulations" ' <br /> Date _ e - <br /> Pnnted/Typed Name r �� , Signature <br /> Z?5.112? <br /> 4,TRANSPORTER i ADDRESS <br /> �hygi j,9 a Tpf*tufPi�b11m°'nt• Applicable Permit Numbers <br /> Cr ecii.1 <br /> Steie, T-nr:•. 1 j�iulaaZ FIs 0 <br /> 1-- 4135 W. Swift St <br /> t' <br /> N E'reano,CA 93722 t: <br /> a a TRANSPORTER CERTIFICATION Receipt of medical waste as described above. <br /> / Y Date <br /> ~ Print/Type Name '' �' i "Signature <br /> ,.: Phone# <br /> _ 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Applicable Permit Numbers <br /> N W <br /> UJI <br /> It UJ-J <br /> z EE a INTERMEDIATE HANDLER t TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> 4? Signature Date <br /> 1- Print/Type Name Phone# <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Applicable Permit Numbers <br /> ~ J <br /> N0 <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> w_ _Date <br /> s Print/rype Name Signature <br /> ~ 7.DISCREPANCY INDICATION , —CU 111 to : Wift SO Lake,UT <br /> / ❑ BD Alternate Facility: <br /> a Be.Alternate Facility: 1 8C.Alternate Facility: <br /> � ��=Ie. <br /> ility: /Gi®,Inc <br /> .Inc. Inc' 2775 E.2W St <br /> Inr: 3Q�,4.T <br /> �p 41 Vernon.CA 908 <br /> a Fre i t A 93 St UT (323)362 <br /> u. Frat�to.C'A 53722 X310)S�'2477 <br /> Z E� t$59T 2TS 1121 tool)JL4- T�31/T960.�5 TS/OST 2fi <br /> W TSX)S T2z <br /> a <br /> 36 <br /> gI.0 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that have <br /> p- @m received the above indicated wastes In accordance with the requirement outlined in that authorization. <br /> Date <br /> Print/Type Name Signature <br /> ii <br /> I <br /> LEA <br /> VE AT GENERATOR <br />