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. CUSTOMER NO.21132
<br /> If.#' ;slat;-;PeoDte-,-.-&edudngel.A: Route #: 34.1 - IQ
<br /> 1.Generator's Name,Address and Telephone Number
<br /> Arrff., Bt:iart HdP-9 q.
<br /> ;m SMGICIAL
<br /> 6001 LoNG'$ 3T
<br /> sTOMT019, CA 95206- 4901 i 482-5199 9y if Z 9 12
<br /> CUSTOMER NUMBER 6016095-00" GENERATOR'S REGISTRATION N
<br /> CONTAINER TYPE 2C. NO-OF 20. VOLUME
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERS
<br /> UN3291,Regulated Medical Waste,n.0 S. TB57 _ rw ;,m� 'Fran i n3.+,a 1 Li cu ft_; Cu Ft
<br /> 6 2,PGII
<br /> UN3291,Regulated Medical Waste,n.o.s., T649 - 37 (Val 3't1L+ {8a t°! 14.9 '='� Ye) Cu Ft.
<br /> 6.2,PGII ( 15.9
<br /> CC UN3291,Regulated Medical Waste,n.o.s. T814 - q9, G (.19
<br /> .a2 TU "1`►) {5.9 Ce! tt) tCu R
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<br /> Q UN3291,Regulated Medical Waste,n.o.s., T82I 20 Gaal T {8ir+i { Cu Ft.
<br /> CC 6.2,PGII
<br /> W UN3291,Regulated Medical Waste,no.s., �.Lrgs - 2e 4;j] TUD ;pdtlt7 47.7 C11Yt i Cu Ft.
<br /> W 6.2,PGII
<br /> 0 UN3291,Regulated Medical Waste,nes., �5 _ 20 mal Tub `!➢aestta a {2.7 cu ft1 Cu Ft.
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o.s.. Cu Ft.
<br /> 6 2,PGII
<br /> UN3291,Regulated Medical Waste,n-o.s., Cu Ft.
<br /> 6.2,PGII Cu Ft.
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately
<br /> TOTALS ► -5 .91 Co Fc.
<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 /> q,.t o a. Signature C Date r.
<br /> PrintedlTyped Name �{ i o'^ Phone Ii: f sv d3:•81 2� r'y��
<br /> CC 4.TRANSPORTER 1 ADDRESS: :�12?a 7A� r1 `1j"I}tz�aL�D'! :Sh'l�"-n°�Gr Appkcable Permit Numbers:
<br /> s•FW-'
<br /> a rres o,r...A 43722
<br /> i QTRANSPORTER CERTIFICATION: Receipt of medical waste as described above. -
<br /> lL . j t
<br /> Signature Date
<br /> Printlrype Name Phone#-
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Applicable Permit Numbers
<br /> J W
<br /> 02M
<br /> •r3ujJ
<br /> i20 RANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> INTERMEDIATE HANDLER/T .
<br /> Z Signature
<br /> Date
<br /> Print/Type Name
<br /> Phone#
<br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Applicable Permit Numbers:
<br /> ;a¢
<br /> :OJ
<br /> Z' INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> w= Date
<br /> i~ Signature
<br /> Z Print/Type Name
<br /> 48A.
<br /> REPANCy INDICATION +C�` °UT
<br /> Trolls d cont
<br /> Designated Facility: 88.Alternate Facility: ❑
<br /> BC.Alternate Facility; ❑80.Alternate Facility:
<br /> SW
<br /> 7 swky.*.Inc. ybaricycte'Inc. Z Atttotllo 2775 .26th St,
<br /> 9Q NOM/100 W6Cel 84594 Vemon,CA 90053
<br /> 419f+W. ` g W Ladle,UT � :?:3l�7_;tyrut
<br /> 1 FYesnw,l^�►93722 ( t D M 1565 (5 t 0)50°-.0 t'7
<br /> (S )275-11121 3A-448•.W36 MINSfOS'T23 T3110ST=25
<br /> TSKW22
<br /> TREATMENT FACILITY: 1 certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name
<br /> Signature Date
<br /> LEAVET GENERATOR
<br />
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