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0 <br /> – Rk ReAutl gRik �� _ 19CUSTOMER Nu.2113'L ✓® ME11 OOC UP6 <br /> R J<oute 8: <br /> t.Generator's Name,Address and Telephone Number Z <br /> ATTN: Brian Hansen <br /> MU SURGICIAL <br /> 6801 LOWIZ ST <br /> STOCKTOV, CA 95206- 4907 (209) 982-5199 7/20/2012 <br /> J <br /> GENERATOR-s REGISTRATION# <br /> CUSTOMER NuMaER 6 5-00 2C. NO.OF 2D. VOLUME <br /> 2A.DESCRIPTION OF WASTE <br /> 28 CONTAINER TYPE CONTAINERS <br /> UN3291,Regulated Medical Waste,n o.s, Cu Ft <br /> 6.2,PGII q'$5? – 90 Gal Tub ($io} (12 Cu Et? <br /> UN3291,Regulated Medical Waste,n o s T049 rTub_ 37 al (1110' (4.9 CU tt) Cu Ft <br /> 6.2,PGII C `� ,�'i <br /> pC UN3291,Regulated Medical Waste,n.o s., T914 _ 44 Gal TUb($1O} (5-9 CU ft} Cu Ft <br /> ® 6.2,PGII <br /> I ' UN3291,Regulated Medical Waste,n o.s,. TB21 _ 80 teal Tub(tt3s o} (2.7 Cu ft} Cu Ft <br /> 6.2,PGII <br /> CC <br /> W UN3291,Regulated Medical Waste,nos, T815 – 20 Gal Tub 4Pa ) 42.7 -CU ft) Cu Ft <br /> W6.2,PGI{ <br /> UN3291,Regulated Medical Waste,0.0 s., Cu Ft <br /> 6.2,PGII <br /> ?X15 – ZO Qe1 Tub (Chemo) (2.? cu ft) <br /> UN3291,Regulated Medical Waste,n.o.s.. Cu Ft <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,no s., Cu Ft <br /> 6.2,PGII Cu Ft <br /> —43036 <br /> OrA <br /> T3Gener's Certification:"I hereby declare that the contents of this consignment are fully and accurately <br /> T®TaLS ► 7 Cu Ft <br /> placarded,and <br /> ove by the proper shipping name,and are classified,packaged,tmark®n al and and <br /> ll on/al governmental regulations" <br /> pects in proper condition for transport according to app ' r <br /> Ste" Signature 2 Date '– <br /> /Typed Name Phone# (559)275-0994 <br /> . RTER 1 ADDRESS: <br /> Cr $t9Ci�t:ler Inc. 1� 1� Throuyh1>FetDEtEl�pplieable Permit Numbers: <br /> > 4]35 U. Swift St i Hauler: Regi <br /> °tea Fceanci,CA 93722 <br /> d a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> T e ., u 1Y ez. Signature <br /> Date <br /> ~ Print/Type Name n v Phone#. <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Applicable permit Numbers <br /> - <br /> r <br /> ChC t2i2i 0 <br /> i; aRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> INTERMEDIATE HANDLER!T . <br /> =r– Date <br /> r Print/Type Name Signature <br /> Phone# <br /> m 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Applicable Permit Numbers. <br /> JQQ <br /> W J <br /> n s< INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> F= Date <br /> c_ Print/Type Name Signature <br /> VBA. <br /> PANCY INDICATION <br /> ® di itbD: N Loh,UT <br /> TranSbWed <br /> ,. ignated Facility: <br /> Be.Alternate Facility: ®8C.Alternate Facility: 80.Alternate Facility: <br /> .tai. tftC.. St~@.Inc. <br /> Inc. SM p 2776 CE,2M gt. <br /> 3 4135 W.SVWt St 90 1100 Vernon. A 9D058 <br /> '� Rrat;>nc.CA 83722 North .t!r (510)562-2177 HfffAwd.CA 94W (823)362 311x0 <br /> (689)275.1121 (out) 1 T�331 -26 <br /> s 22 B,Ih-3fi <br /> C <br /> L TREATMENT FACILITY: I certify that I have been authorized by 4he applicable state agency to accept untreated medical wastes and that I have <br /> .0 r, received the above indicated wastes in accordance with the requirement outlined in that orization. <br /> Date <br /> Pnnt/Type Name Signature ra <br /> LEAVE AT GENERATOR <br />