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-1.t3enera4or's Name,Address and Telephone Number <br /> Brian Hanson <br /> ATTN- _ <br /> SRI 107IRGIC'IAL + <br /> 6801 LLMC-Z ST 45206-- 4907 r� :_+:, 01. <br /> STOCKIVII, CA (209) 982-5194 <br /> CUSTOMER NUMBER �I0160t)5'00.:. GENERATOR'S REGISTRATIONk N <br /> CONTAINER TYPE <br /> 2A.DESCRtPTiON OF WASTE 213' e;u ftd Cup F1 <br /> TD57 - 96) Gal Tota (8i-�tUN3291,Regulated Medical Waste,n o s,6.2,PGII .p, ft?UN3291,Regulated Medical Waste,n o s. TB49 - 37 Gal TUD i RIO) t"¢"�6 2,PGII €UN3291,Regulated Medical Waste,n o s. T914 - 9+l rel T1 tB1rif •- U6 2,PGII LIN3291.Regulated Medical Waste.n o s. pt321 _ 2Q t3a1 Tui±(Bir:) (.^6 2,PGII E 2 ? 'L1 t> 7ti UN3291,Regulated Medical Waste,n o s, T815 - {I i3A1 2ub 'lPat.3"s 62,PGII T fC1 <br /> Ul UN3291,Regulated Medical Waste,n o S. •CYZ S _ i0 t3R1 Tub 4t-'b'•`S°�-1 <br /> 6 2 PGII Cu F+ <br /> UN3291,Regulated Medical Waste,It o S. <br /> Cu F <br /> 6 2,PGII <br /> UN3291,Regulated Medical Waste,n o s. <br /> 6 2,PGII Cu F <br /> 4. <br /> * nd TOTALS ► ' Cu F <br /> 3.Generator's Certihe proper ish ppin9d ameeandtarle classified,packaged,me contents a a ed and f this consignment are tlabely aed/placarded,and <br /> described above by licable international and national governmental regulations" <br /> are in all respects in proper condition for transport according to app ` <br /> 1 r Date <br /> ��, ` L•n I Signature - <br /> Printed/Typed Name Phone a (�JJ41 7 y_'.rQ94 <br /> .TRANSPORTER t ADDRESS 1 J i.5 a Through 5h i♦r$ltiF.•rit Appncabie Permit Numbers <br /> 4 <br /> oe Ste swift <br /> Znr_. B,,uz�c Re-00 <br /> 41:35 6i- swift St <br /> i o grepano,CA 93722 <br /> a , <br /> : y <br /> Z <br /> TRANSPORTER CERTIFICATION: Receipt o1 medical waste as describedabove. Date ( / <br /> cc )(I f i ji -L Signature <br /> ~ Phone# <br /> print/Type Name <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Applicable Permit Numbers <br /> 'W <br /> �aW <br /> W J <br /> w= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above bate <br /> z Signature <br /> Phone It <br /> Print/Type Name <br /> 'w <br /> 6-INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Applicable Permit Numbers <br /> Ei'aw <br /> Z INTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> Date <br /> 1--i Signature <br /> z Pr nVType Name <br /> 7.DIS REPANCY INDICATION Trauft"dut ft to ; Noah SA LaM,0T <br /> 11C.A*n3,,eFacility: <br /> 80 Alternate Facility <br /> 88.Alternate Facility: ❑ sftrscycle.Inc <br /> BA.Designated Facility: ❑ � Inc <br /> stwicyde.Mc. 27E.2M SL. <br /> 413b W t SL1 1100►/`ret�t CA 94544 Yerrn .CA 900" <br /> 1 got Late,UT (3231362.74000 <br /> L p�srto,CA 93722 �2-2177 <br /> E275-1120 (80 i)m t sm TS60SZ -o <br /> u tea 436 <br /> TS3t fT9105"1'?5 <br /> �E <br /> he applicable state agency to accept untreated medical waste <br /> +J TREATMENT FACILITY: I certify that I have been authorized by ts and than have <br /> _ received the above Indicated wastes In accordance with the requirement outlined in that authorization. Date <br /> Signature <br /> Pnnt/Type Name <br /> L V T GENERATOR <br />