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® Jarra,.rY yy t CUSTOMER NO.21132 jjFRQQ$IJ1D
<br /> O.® pW.-&:People pad..n0dW: Route T: ���• '— 13
<br /> I.Generator's Name,Address and Telephone Number
<br /> ATTN: Brent Beers I�
<br /> SRI S(IRGICIAL
<br /> 6801 LO1iiGC' ST
<br /> —,roO'K' N, CA 95206- 4907 (209) 982- 199 1/ +I gal
<br /> CUSTOMER NUMBER
<br /> 095-002 GENERATows REGISTRATIONg
<br /> 2C. NO.OF 20. VOLUME
<br /> CONTAINER TYPE
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERS
<br /> UN3291.Regulated Medical Waste,n.o s., Cu Ft.
<br /> 6 2,PGII Tt35'1 - 90 tial dub {T3%o) {22 Cu
<br /> 7`t)
<br /> UN3291,Regulated Medical Waste,n.o s., ,PBA 9 — 37 Coal Tub (Bio) ( •9 N ft) Cu Ft.
<br /> 6.2,PGII
<br /> p� UN3291,Regulated Medical Waste,n.o s., `P814 - 44 Gal Tub(Vil.o) (5-9 CIS Cu Ft.
<br /> 0 6 2,PGII
<br /> Q UN3291,Regulated Medical Waste,n.o s..
<br /> TS21 — 20 tial 'tub(Si e) (2.7 Cu ft) Cu Ft.
<br /> 6.2,PGII
<br /> W UN3291,Regulated Medical Waste,n-0 S., T815 — 20 Sal TUD (Paull) 42-7 cu Y1:) Cu Ft.
<br /> W
<br /> 6.2,PGII
<br /> UN3291,Regulated Medical Waste,n.o s., 4`Y15 — 20 43d]. Tub (C'h4) 42.7
<br /> Cu EG) Cu Ft.
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> UN3291,Regulatea Medical Waste,n.0 S..
<br /> 6.2.PGII Cu Ft,
<br /> UN3291,Regulated Medical Waste,n.o s.,
<br /> 6 2,PGII Cu Ft.
<br /> FIlamaceutiCal Wa13
<br /> TOTALS ► � s . ' Cu Ft.
<br /> 3.Generator's Certification:"1 hereby declare that the contents of this consignment
<br /> arc
<br /> a d lalbelaled/placardend d and
<br /> described above by the proper shipping name,and are classified,packaged, !
<br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations.`
<br /> r� II c , 9
<br /> V P `�� I Signature if. 6 Date G
<br /> Printei/T ped Name Phone a_ (EeSg)_7 7.9
<br /> 4.TRANSPORTER 1 ADDRESS: ,rhl� 3 Shiptnent Applicable Permit Numbers:
<br /> w Stericycle, Inc:. Hauler Reg* 3400r 4235 tit Swift. Ave..
<br /> a Fresno,Ca 93722 ,
<br /> - N
<br /> = z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> et L� "�- Signature Date
<br /> LZ~ Rt -r—'6A4,Pnnt/Type Name �, � ��--� Phone 9:
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: f• Applicable Permit Numbers:
<br /> iW I
<br /> iQ ac
<br /> •OW
<br /> i,Z!
<br /> = INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. .
<br /> Date
<br /> Signature
<br /> Print/Type Name
<br /> Phone A.
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS' Applicable Permit Numbers-
<br /> Uj
<br /> iQ¢
<br /> VQ a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br /> LU z Date
<br /> zSignature
<br /> Print/Type Name
<br /> 7.DISCREPANCY INDICATION R t9 ,UT
<br /> TMIS11111"d CU
<br /> BA.Designated Facility: ❑88.Alternate Facility: ❑
<br /> 8C.Alternate Facility: ❑80.Alternate Facility:
<br /> Ste @ I,w- hKb" 2775 s`$TI"I a 1 R!*E T
<br /> J S'tsricy�de Ina-A 1 IndrWatiOn 1345 D&O still,C
<br /> 4135 W.SWIFT AVE NORTH SALSO NORTH IT CITY.U Son L e CA VERNON.CA WIM
<br /> L FRESNO,CA 93722 510 X62-2 t T7 (323)362-3000
<br /> ( 1121 X1)9 -3665 tT'S'31 . ?3 'i'.+KST-c6
<br /> applicable state agency
<br /> to accept untreated medical wastes and that I have
<br /> U TREATMENT FACILITY: I certify that I have been authorized by the app" 9
<br /> _ received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> � Date
<br /> Print/Type Name Signature
<br /> LEAVE AT GENERATOR
<br />
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