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0 <br /> RROu(I• Rn4 CUSTOMER NO.2119 '1^f 1 R-I <br /> F;u�RRm9RtRyR outs 301 3.3 <br /> 1.Generator's Name,Address and Telephone Number <br /> • Brian Hanson <br /> ��. I i I II <br /> SRI SURGICIAL <br /> 6801 LORM ST <br /> STOCKTOW, CA 95206- 4907 <br /> 2091 982-5198 <br /> CUSTOMER NUMBER —0 12 <br /> GENERATOR'S REGISTRATION p <br /> CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> 2A.DESCRIPTION OF WASTE 2B• CONTAINERS <br /> UN3291,Regulated Medical Waste,it o 5, 1Cu <br /> 62,PGII - go Gal Tub 8i4 LIZ Cu ft <br /> UN3291,Regulated Medical Waste.n o s, ru tt) Cu <br /> 62,PGII T649 - 37 Gal Tub (Di0 (4,9 I <br /> Cr UN3291,Regulated Medical Waste n o s, Cu <br /> ® 6 2.PGII T914 - 44 tial Tub(Hio) (5.9 cu !t) <br /> Q UN3291,Regulated Medical Waste n o s, T821 - 20 tial Tub OKO) (2.7 Cu ft) Cu <br /> a 6 2,PGII <br /> W UN3291,Regulated Medical Waste.n o s. Cu <br /> Z 62.PGII T815 - 2U Gal. Tub (Path) 42.7 ,Cu ft) <br /> W dical Wan UN3291,Regulated Meste. o s, Cu <br /> 0 62,PGII 15 - 20 t3al Tub (Chemo) 2.7 Cu ft <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 /> 1 � <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment 4135 N. Swift St are fully and accuratelyded, d <br /> TOTALS ► <br /> cc <br /> Cu <br /> described above by the proper shipping name.and are classified,packaged,marked and labelled/placaran <br /> are In all respects in proper condition for transport according to applicable International and national governmental regulations' , <br /> Signature <br /> Pnnted/Typed Name <br /> r <br /> Phone (559)4-75-0994 <br /> 4.TRANSPORTER 1 ADDRESS' <br /> cc <br /> W $t@CieyCle, IRC• This 1s d`Throe h S`lllpAli�Tl� iiPpllcable Permit Numbers <br /> sulee Fte:gl <br /> 0. FCesnci 93722 <br /> a a TRANSPORTER CERTIFICATIONReceipt of medical waste as described above 'f y <br /> .l <br /> i ft Y Gl Signature <br /> Print/Type Name - � Phone p <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS, Applicable Permit Numbers <br /> r' <br /> w <br /> uaw <br /> nwINTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> I.- Date <br /> m Print/Type Name Signature <br /> Phone lt <br /> Lu 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESSr Applicable Permit Numbers <br /> cuaQ <br /> C W W <br /> 3¢a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above — <br /> W= Date <br /> c z Print/Type Name Signature <br /> 7.DISCREPANCY INDICATION Troaftned <br /> °u it to : North Sall Lalro,lff <br /> BA.Designated Facility: 8B.Alternate Facility: <br /> 8C.Alternate Facility: F]BD.Alternate Facility: <br /> � 9GgrlcVcE@,Inc. <br /> a Inc. Inc. 27TG a•2M St <br /> StBrlcyc.k'a.Inc. 2 � ,�q�� <br /> i a 4135 W.$NAR St .� t/ �/ip„.w•.Ca � <br /> Fresna,CA 93722 North SO Ldre.IIT fg'p}562-2177 (3231342-3000 <br /> — $ (569)275-1121 (801)936-1655 TS31nVOST25 TSfOST-26 <br /> g TSOST22 36 <br /> I certify ncy to accept untreated medical wastes and that I have <br /> g a TREATMENT FACILITY: y that I have been authorized by the applicable state age <br /> it- received the above indicated wastes in accordance with the requirement outlined m that authorization. <br /> Date <br /> o Print/Type Name Signature <br /> LEAVE T GENERATOR <br />