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w...v s•s...y.s __ _. _..._._--..- -- r.N <br /> • vroremyveopie ReeunngRisY- Route 0: j(f) _. } CUSTOMER NO.21132 [i}� <br /> 1-Generator's Name,Address and Telephone[Number i 1111111111111111 NrT'N:Brian Hanson <br /> aftL 3tx1Z(;x YakL <br /> 681)1 LONGE 5T <br /> �iTLti.liTUi91. r-A 9520 ;- 4907 14112:•:.''4011_ <br /> (2091) #82--5194 <br /> CUSTOMER NUMBER 6016095—002 GENERATOR'S REGISTRATION# <br /> CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> 2A.DESCRIPTION OF WASTE 2B t CONTAINERS <br /> UN3291,Regulated Medical Waste.n o S, T805 _ 40 GA1 that (sit,) 5,1 CU ft) Cu t <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n o s. TTI$q, .. 17 Gal g41b UrJ4,.r) !(4.4 CU ft) Cu 1 <br /> 6 2,PGII <br /> CC UN3291,Regulated Medical Waste,n o s, T014 _ 44 6411 Tib(Bir,) (5,9 GT1a ft) Cu I <br /> ® 6 2.PGII <br /> ~Q UN3291,Regulated Medical Waste,n o s, T13°21. - 20 Gal Tota t sirs) (2-7 Cu ft) Cu I <br /> CC62.PGII <br /> W UN3291,Regulated Medical Waste.n o s, TR15 - 20 Gal Tub (Path) 12.7-cu tt) Cu f <br /> Z 6 2,PGI I <br /> W UN3291,Regulated Medical Waste.n o s. Cu F <br /> 6 2,PGII TY15 - 2(1 tel Tub (CTaemca} {�,? cu ft) <br /> UN3291,Regulated Medical Waste,n o s, Cu F <br /> 6 2,PGII <br /> UN3291,Regulated Medical Waste.n o s. Cut <br /> 6 2,PGII <br /> Cu F <br /> " ' - TOTALS 1100- ! j a,I <br /> 3.Generator's Certification:-I hereby declare that the contents of this consignment are fully and accurately <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 international and national governmental regulations'. <br /> fill., /C Signature " Date <br /> Pnnted/Typed Name # <br /> Phone <br /> .\ t55co)115.. 113. <br /> 4.TRANSPORTER IADDRESS ,f <br /> W afigC1L�/+���i Inc. nt:l5 13 d �iPtroug:l Shi rl%pplicable Permit Numbers <br /> 4135 a. swift St <br /> N Fcesno,CA 9:3722 <br /> a q TRANSPORTER CERTIFICATION: Receipt of medical waste as described above ! <br /> CC —N Dale <br /> _ y Dale j <br /> Print/Type Name ° Signature _ Phone# <br /> INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Applicable Permit Numbers <br /> V W <br /> _UJ <br /> 3. <br /> Z W a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> CC z Date <br /> = PnnUType Name Signature <br /> Phone# <br /> w S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Applicable Permit Numbers <br /> .0 <br /> =W J <br /> s INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt or medical waste as described above. <br /> w Date <br /> X z Print/Type Name Signature_. <br /> 7.DISCREPANCY INDICATION T e��_�_'OU g to : NedLAW,UT <br /> j i E] 8D.Alternate Facility: <br /> BB.Alternate Facility: ®8G.Alternate Facility: <br /> A.Designated Facility: ry�^wr_'Ycle,Inc <br /> 175 <br /> s'Lar(cycle,Inc swftycle.Inc. 21r.,E 2M St <br /> i 4t33 W.S'1�t� �NtatfN 17� SQ�2� 8d� Ytn.Cis 99053 <br /> u F'resw.CA 93772 N11rCh S 1323)362-30W <br /> TS OST TWOST 215 <br /> � (t3$9)276-1121 (int) 1555 T331�J�9"C25 <br /> � s TS(OST22 B,3f�-36 <br /> a $ <br /> pt untreated medical wastes and that 1 have <br /> W TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to acce <br /> l'- received the above Indicated wastes in accordance with the requirement outlined in that authorization. <br /> _ Date <br /> Pnnl/Type Name Signature <br /> LF-AVE AT GENERATOR <br />