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<br /> ®• Stericycle" CC y CUSTOMER NO.2113
<br /> ®® fiotetil9 People.Redad.9 Nu ',t' Li t r_' W w tt I, ►--�-
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<br /> 1.Generator's Name,Address and Telephone Number
<br /> APijj: Brian Hanson
<br /> milli111"00111
<br /> SM stW(G¢�LYAld
<br /> • w
<br /> 6801 W)IM ST
<br /> STCGMiN, GA 95206- 4907
<br /> (20!a) 922-5199
<br /> 01�095-002
<br /> 6l 9 5^0 0 2 GENERATOR'S REGISTRATION#
<br /> CUSTOMER NUMBER `x.V�J E.i i. 2C. NO.OF 2D. VOLUME
<br /> 2A.DESCRIPTION OF WASTE
<br /> 2B CONTAINER TYPE CONTAINERS
<br /> UN3291,Regulated Medical Waste, .o.s., Cu Ft
<br /> n
<br /> 6.2.PGII T8.57 - 9t? rf,it3 dub (riirl? 1,1? •�tl $3�
<br /> UN3291,Regulated Medical Waste,n.D.s., ,�849 - 37 C;a3 Yut� fBar CuFi
<br /> 6.2,PGII !! rt
<br /> UN3291,Regulated Medical Waste,n.o s., T814 _ 44 ;-al Tl3h{t:i'•+ 5 .y =l, tt i Cu FI
<br /> ® 62,PGII
<br /> UN3291,Regulated Medical Waste,n.o s, gggl - 2 3:x1 'Flab tai r•9 {>. •.ra t't.'• Cu Ft
<br /> Q 62,PGII
<br /> W UN3291,Regulated Medical Waste,n.o.s., S'E15 _ 20 r al Tt;ka (Patks} .::.7 wel tt`> Cu Ft
<br /> Z 6.2,PGII
<br /> W UN3291,Re ulated Medical Waste,n.o.s, Cu Ft
<br /> C) g 2'1'15 - 241 Gal Tab4Ctaera„+ •:2 :,ts tf:}
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n,os, Cu Ft
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o s., Cu Ft
<br /> 6.2,PGII
<br /> Cu Ft
<br /> Pharmaceutical spas I �`
<br /> 3.Generator's Certification:"1 hereby declare that the contents of this consignment are fully and accurately
<br /> TOTAL S /' Cu Fi
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded.and
<br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations!
<br /> '-
<br /> Printed/Typed Name t
<br /> Phones
<br /> (ss 9)27.
<br /> 4.TRANSPORTER 1 ADDRESS:
<br /> w a$lEg3L^jC1lE, Inc. This 3.3 a TI S 11 ipment Applicable Permit Numbers.
<br /> Q ir 4135 tit:. SWiit= AVe. mauler F.�g� 340n
<br /> g o0 Fx-ezno,Ca 93722 � t
<br /> w
<br /> a Q TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> I`•
<br /> Q Print/Type Name 1 ' I!/• Pe"I )'� Signature , -f
<br /> Phone#.
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS f
<br /> Applicable Permit Numbers.
<br /> u•t¢
<br /> ui
<br /> two
<br /> wT INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> _ Date
<br /> PrinVType Name Signature
<br /> Phone a:
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS.
<br /> w Applicable Permit Numbers.
<br /> uaW
<br /> =wJ
<br /> a a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br /> z Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> nS mda4mrs, cit R to : Noah Salt Lake,UT
<br /> aA.Designated Facility: Be.Alternate Facility: ❑
<br /> J
<br /> BC.Alternate Facility: BD.Altemate Facility:
<br /> lUtiXAM
<br /> �� If1'-AstiBrf Irtc tvets?tarl deine-A tttr_•AUtvCav
<br /> 41 N W.S'WiFT AVE 90 N i 100 o ' !X45 I ra Ste C �
<br /> �77�a E Eil?t MEET
<br /> ,. t'RE3IVU.C/►43722 NCR7 i SALT'L CITY,L Sara Lrawdro,CA 94677 VERNON,CA $I:I�J23
<br /> (5f59)275. 1121 (Sat f m- 1555 (510)5`32-2177 t333)362-3f300
<br /> 3�l A�b8-►�.-36 'TS3I1TS TAB TSIOS'T s5
<br /> ji hTREATMENT 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 Signature Date
<br /> LEAVE AT GENERATOR
<br />
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