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<br /> Psepte.Pedud^9 Risk' e - � CUSTOMER NO.21132
<br /> r4r�^aCio'it
<br /> Prot�dn9 .
<br /> Generator's Name,Address and Telephone Number ,
<br /> it
<br /> ATTP&s Brian Hanson 3
<br /> SRI SIMISICIAL '
<br /> 6001 LOW;E ST
<br /> STOcIMV, CA QS2015- 4941'7 ..� .::i�:►l
<br /> � •o5t 981-519
<br /> GENERATOR'S REGISTRATION#
<br /> CUSTOMER NUMBER t '_ fl'? 2C. NO.OF 2D. VOLUME
<br /> 2A.DESCRIPTION OF WASTE
<br /> 2e CONTAINER TYPE CONTAINERS
<br /> Cu Ft
<br /> UN3291,Regulated Medical Waste,n os,
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<br /> UN3291,Regulated Medical Waste,n o S. ` _� �*
<br /> 62,PGII '£849 - 37 coal Tut- r$irep $4 1
<br /> UN3291,Regulated Medical Waste,n.o s. 22 %I? Sc Cu Ft
<br /> � 62.PGII TFs19 - 49 +�.1 'Jt1I2tFsir.; $S.9
<br /> F UN3291,Regulated Medical Waste,n.o S. 2Q i3%sl $e�brSa" Cu Ft
<br /> Q 62,PGII T82i •� i✓ i°.'•
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<br /> W UN3297,Regulated Medical Waste,no.s, T815 _ 2At;ti %cit• ¢�1~eYJ;. 4<< '
<br /> � 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n o.s., Cu Ft
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<br /> UN3291,Regulated Medical Waste,n.o.s,
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<br /> UN3291,Regulated Medical Waste,n.o S,
<br /> 62,PGII Cu Ft
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<br /> a rm a TOTALS ► J . � r Cu Ft
<br /> 3.Generator's Certification:"1 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! r
<br /> Signature Date
<br /> Pnnted/Typed Name Phone#: c r:- G 0
<br /> 4.TRANSPORTER 1 ADDRESS: X591�7.: (I..
<br /> � °f'f7S:� 1w � fit- io,J,gjJ S�D1p7iI�tRtAPPlicabie Permit Numbers
<br /> W steLi� t"le, Inc. C`�
<br /> �� Hain+_[• T40--g4
<br /> cc 4135 d. Swift St
<br /> N 'Freana,C—A 93122 /I r
<br /> Z< TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> 7 Date
<br /> I- Print/Type Name n '' `� "/ -, " i),-,t Signature
<br /> ` Phone f1:
<br /> 5.INTERMEOIATE HANDLER 2/TRANSPORTER 2 ADDRESS: } Applicable Permit Numbers
<br /> uam
<br /> 0
<br /> g W= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> =t- Date
<br /> x z Print/Type Name Signature
<br /> Phone#.
<br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Applicable Permit Numbers.
<br /> U4Q
<br /> W W
<br /> LER< INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> •UJI z Date
<br /> c PrinVType Name Signature
<br /> 7.DISCREPANCY INDICATION
<br /> Toms3 kind _ to A to : Wh Sal rake,UT
<br /> 8e.Alternate Facility: ®8C.Alternate Facility:
<br /> 8D.Alternate Facility:
<br /> ,,. 8A,peslgnated Facility: ❑ _
<br /> �rfci�,lrw- Sterlt-4.ie,irc
<br /> Sterkytle.Inc �" eeic{c+,Inc q X542 eaxi S73sad 2775 E-210 St
<br /> t#tl Iyerfb I it39 t
<br /> 4936 W.Std St fv�urll't 5a�t Lie•7J7' �I t�p�'arA,CA 94 V41710",^r. 3003%
<br /> _ Fri3 M CA 937.,2 590E x-2277 1'323136 3000+
<br /> U (M)276-1121 (set)931¢9m T } 33tt3S1=?6
<br /> tr' TSIOST22 3t44t3".tf+t-36 f 3 5
<br /> s
<br /> L TREATMENT FACILITY: I certify that M have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> _ ce with the requirement outlined in that authorization.
<br /> received the above indicated wastes in accordan
<br /> PnntRype Name
<br /> Signature Date
<br /> LEAVE AT GENERATOR
<br />
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