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ts•®® Stericycle* JOSE OF EMtMIitNUT UUN IA41:1-MM I mca. -ovv-vcY'' <br /> • PMectlnBftWkRedud°9fl1A_ '�„ � - e ��"��' r 1� CUSTOMER NO.21132 t�Qi�I;ROOEM7fc <br /> 1.Generator's dame,Address and Telephone Number1111111115111111111111011111 ATTN:Br-iian Hanson <br /> SRI SURGICIAL <br /> 6001 LONGE ST <br /> STOCiE'mys, CA 95206- 4907 <br /> (209) 982-5199 12161j .'ot:; <br /> CUSTOMER NUMaER 6016095-002 GENERATOR'S REGISTRATION a <br /> 2A.DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> CONTAINERS <br /> UN3291.Regulated Medical Waste,n o s. TV05 - 40 Dal TUb ( a) f.5-3 cu ft a Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n o.s, T049 - 3-1 tial 'Tub (Bi(P) (4.9 CU Eta Cu Ft. <br /> 6 2,PGII <br /> CC UN3291,Regulated Medical Waste,n o-s., T814 - 44 Gall Tub(Bio,) (5-9 cu ft) ` Cu Ft. <br /> ® 62,PGII - <br /> UN3291,Regulated Medical Waste,n o-s. u Bio t cu t <br /> Q Cu FI. <br /> 62,PGII <br /> CC <br /> W UN3291,Regulated Medical Waste,It o s, TP25 - 20 Gal 'Tint fPath) (2.7 lett tffi) Cu Ft. <br /> Z 6.2,PGII <br /> W UN3291,Regulated Medical Waste,n o.s., Tyg5 - 20 dMal Tub (chemo) (a.7 cu ft} <br /> � Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,It os, VMS - Biox,19tems Cardboard Box (4.2 cu ft) Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,—.0 S., Cu Ft. <br /> 6.2,PGII <br /> Pharta$C60t3.Cal tB69". Cu Ft. <br /> Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately <br /> TOTALS ® v r <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 /> 1 ��/P/'- Date <br /> Pnntecirryped Name Signature Phone u (r+. 1 Z 4.TRANSPORTER 1 Alf <br /> RESS Th13 is a Thtnaag't Btti}stnettt <br /> g+ag Lcyv- e: '�ffiC. Applicable Permit Numbers <br /> 4135 9. Swift: AV�i t�ulvJc R�r�� ��QL�lZ <br /> aCC <br /> o Ftreeno,CA 93722 1 <br /> cn / <br /> rn <br /> 2 Q TRANSPORTER CERTIFICATION:ReceiptLotmedic-al waste as described above. ,,,OC DatePrint/Type Name 1 I} r � 'C Signature <br /> ` Phone N. <br /> ;INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS 6' Applicable Permit Numbers- <br /> )1L <br /> 1QQ <br /> :OJ <br /> swiq <br /> icc= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> � Date <br /> Print/Type Name Signature <br /> Phone# <br /> W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS- Applicable Permit Numbers: <br /> icor <br /> -OW <br /> W <br /> Q a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> w= Date <br /> i z Signature <br /> _- Print/Type Name <br /> 7.DISCREPANCY INDICATION ,s to a Haft&fit Lake,UT <br /> BC.Alternate Facility: El OD_Alternate Facility: <br /> BA.Designated Facility: E]8B.Alternate Facility: 11stilwicyaw.�� 9 Iris <br /> WC. 90 N.FC06?!11 0""3 �- 4135 W.910 AVG 90 N• 1 11 n M CA MW North SA LOM-LIT 134 D <br /> t rMario.CA'mmas a f32M 362a00 <br /> � 0 <br /> (IW 275.1121 6301 936-1655 4 <br /> 031)T3I0aT 03 TWOST-25 <br /> TS/OST22 JA-36 <br /> 191s <br /> r o TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br /> received the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> tl Date <br /> Print/Type Name Signature <br /> LEAVE AT GENERATOR <br />