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®®®® Stericytle' IN SE OF EMERGENCY CONTACT:CHEMTREC 1-8004214j6 STANDARD MANIFEST 001-10-06-STD
<br /> •
<br /> PmeaingPwple.Aedudngeisk: 2�� 14CUSTOMER NO.
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<br /> 1.Generator's Name,Address and Telephone Number
<br /> li'I"d'ltl e Bt:1 an • If dY:+tiefl: { C 8 i
<br /> SRT SlgRGTt.:IAL f t ! 1
<br /> 001. �lP�L1C��tNG.F. 3T 4907
<br /> CUSTOMER NUMBER -t-t 4ef•Z Cf Y t .y GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B• CONTAINER TYPE 2C. NO. 2D. VOLUME
<br /> CONTAINNERS
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII 'ii r20. sib i�d.;,'. j.? =.*:f t r? Cu
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 62,PGII T'S4 9 37 G; I Tk-1< t I# i 9.`? Cf,6 I 5 Cu
<br /> C UN3291,Regulated Medical Waste,n.o.s.,
<br /> 62,PGII `i°Fs'14 44 t4al TubmL ,: <5 4 c-.3 f r A v ( Cu
<br /> = UN3291,Regulated Medical Waste,n.o.s., r�2�T _ yt� , T,2p, S =y {2.'? ;,ts ft,i
<br /> 6.2,PGII Cu
<br /> UN3291,Regulated Medical Waste.n.o.s.,
<br /> 6.2,PGII T$1.`. 211 (�a1 Tuk OPatb) It ft.! Cu
<br /> u UN3291,Regulated Medical Waste,n.o.s, -
<br /> 6.2,PGH . TY15 20 r,aI Tull tCheM,_,! Cu
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> Cu
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> Cu
<br /> 6.2,PGII
<br /> Cu
<br /> oil
<br /> 3.Generator's Certification:"1 hereby declare that the contents of this consignment are fully and accurately TOTALS ® ! 5 [ Cu
<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:' I
<br /> Printed/Typed Name Signature Date
<br /> 4.TRANSPORTER 1 ADDRESS: Phone#:
<br /> Th tAPPlicable Permit Numbers:
<br /> Fw— att 1r jr�'Ir[ r I73t a r'
<br /> 0 4135 West 3wstt. .Av�.. : ,,r ? r�,,.�r d►ft.t
<br /> CA F'x,eznoX
<br /> z¢ TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. ?
<br /> ~ Print/Type Name > ' -G Signature Date
<br /> Phone#:
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br /> Applicable Permit Numbers:
<br /> Q W .r
<br /> 0 J
<br /> W G
<br /> �= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> W
<br /> Z
<br /> Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
<br /> a�
<br /> OJ
<br /> Q0
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> ul
<br /> z Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> 1'rwa r , --—cu Ito : Nedh UN Laker,UT
<br /> SB.Alternate Facility: 8C.Alternate Facility: ❑ BD.Alternate Facility:
<br /> BA.Designated Facility: ❑ ty'
<br /> � C'16r ir4:.-�'.UtK1dQVr
<br /> St�late-At.�deve Stericycle In Inr� ran Steri e Inc->�t kictave Sb �2�"I�i A-UtO av
<br /> ? q 135 W.SWIFT AVE90 NORT^l 1 I0t t�' 13R� � e C
<br /> �lMI O?S,CA 3,3023
<br /> i=R Ni�.t 34'2 NORTH!SALT LAKE CITY, `t" Saga Leandro
<br /> Gia ��7� i 323)35e- 30 NO
<br /> t i/6- 1121 $801)06- I5v �atl?)'S "- �t7/ AN
<br /> 'i a3«F1 IOST25 fiSf �a
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<br /> J TREATMENT FACILITY: I certify that'l have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H
<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 />
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