|
®® proecMgPoplc.ee0eringRbk: CUSTOMER NO.21132 .
<br /> 331 - 1� L,
<br /> .
<br /> 1.Generator's Name,Address and Telephone Number ] i
<br /> ATTN: Brian Iian--On
<br /> SRR[ S t ROXC$AL t
<br /> 6801 Lr-iWn ST
<br /> GENERATOR•s REGISTRATION
<br /> CUSTOMER NUMBER - •~
<br /> CONTAINERTYPE 2C, N
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERS
<br /> 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o s. Cu Ft
<br /> 6.2,PGII Tl'?:S - •'.a1 Tub "R'iv= 22 :.ti tt
<br /> Cu Ft
<br /> UN3291,Regulated Medical Waste,n.o.s., Gal (Fl2u• 14•c, r_u gtr}
<br /> 6.2,PGII �T84D - 17 Tub
<br /> UN3291,Regulated Medical Waste,n o.s
<br /> 6.2,PGII T814 - 44, r si t gl r?4 (5. r>t ft) Cu Ft
<br /> ®
<br /> 4 UN3291,Regulated Medical Waste,n.o s, ?Tat'w 1 - 20 G&1 Tub(Bio) (2.T crj ft) Cu Ft.
<br /> 6.2,PGII
<br /> W UN3291,Regulated Medical Waste,n.o S. r? 7 Cu Ft
<br /> IZ62,PGII `Fels - 20 Gal Tub (Path) 'Z;.tt Lt?
<br /> Uj UN3291,Regulated Medical Waste,n.o.s., Cu Ft.
<br /> 6 2.PGII TY15 - 20 tial Tub �Che=01 r?--7 ru tt}
<br /> UN3291,Regulated Medical Waste,n.o s., Cu Ft.
<br /> 6 2,PGII
<br /> UN3291,Regulated Medical Waste,n o s,
<br /> Cu Ft.
<br /> 6 2,PGII 0- Cu Ft
<br /> 93% 1
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately
<br /> TOTALS ► Cu Ft.
<br /> -� -
<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 /> U. e.•c I Si nature Date
<br /> PrintedlTyped Name
<br /> Phone M: t 55,a t
<br /> Ir 4.TRANSPORTER 1 ADDRESS: `�r.,_.2
<br /> W St ESS: "yiC1E', Inc. Tl3i1117-1 ' IS a 1Shipment
<br /> Applicable ShipmAPPlicablePermitNumbers:
<br /> i .-F Fabler Retij# 140
<br /> C 4135 Sc---t Sw1ft Aive-
<br /> Nt Frezno,Ca
<br /> TRANSPORTER CERTIFICATION ceipt of medical waste as described abo , .-' t -r
<br /> Cr Date
<br /> ~ Print/Type Name , Ignature
<br /> t Phone M:
<br /> 5.INTERMEDIATE HANDLER /T SR ER 2 ADDRESS: Applicable Permit Numbers:
<br /> W
<br /> Q cc
<br /> O�W
<br /> W= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. `
<br /> � Date
<br /> Print/Type Name Signature
<br /> W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS:
<br /> Phone f+:
<br /> F Applicable Permit Numbers
<br /> a_¢
<br /> J
<br /> Q 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br /> r s Date
<br /> Print/Type Name Signature
<br /> 7/8A.
<br /> EPANCY INDICATION
<br /> Thmbnvd CU!f to . Lanai,UT
<br /> L, signated Facility:
<br /> 88.Alternate Facility: ❑8C.Alternate Facility: 8D.Alternate Facility:
<br /> I g a Its-A utod,ave
<br /> erioide Ino•Inca on Stmit�l InC-Atte
<br /> E Inc-AdodM 134$ Sia C 2776 E 2STM STP.EET
<br /> 41"W,SWPT AVE 90 NORTH ti 1 i I7lY WEST
<br /> ° FR1s IQ•CA 43722 NCRTH SALT d1Y.u Sm L eaft&o.CA 9�I377 JERhIt?N.CA 3t1Q3"s
<br /> •
<br /> (569)775- 1121 (laa I) -lus J610)�2-2177 {328}�3-3+390
<br /> -36 'T-831MVOST25 'P`3MT-21p,
<br /> Taxnm
<br /> !AjTREATMENT FACILITY: I 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 /> LEAVE AT GENERATOR
<br />
|