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•®• stertcycte ... ... _.._......-- <br /> ®• vmteemtPMte Rceowasiu.' RQtlte 0: 301 — 12 CUSTOMER NO.21132 <br /> MDFROOEDHI <br /> 1,Generator's Name,Address and Telephone Num+r <br /> ATTN:Biian Hanson <br /> SRI SURGICIAL i <br /> 6801 L01M ST ` <br /> sTocnow, CA 95200-• 4907 <br /> (209) 902-5199 11/6/2di1's <br /> t t <br /> CUSTOMER NUMBER 6016095-042 GENERATOR'S REGISTRATION g <br /> 2A.DESCRIPTION OF WASTE . 2B. CONTAINER TYPE 2C. NO.CONTAIN 2D. VOLUME <br /> NERS <br /> UN3291.Regulated Medical Waste,n o s. TBG$ — 40 Gail ($io) (5.3 cu ft) Cu Ft_ <br /> 62,PGII <br /> UN3291,Regulated Medical Waste,n.o s, T949 — 37 041 Tub (V,o) (4,9 cu ft) Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste•n.o s, TO14 _ 49 Gal Tu♦b(Vio) (3-9 Cu ft) Cu Ft. <br /> j 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o s-, T121 — 20 Gail Tudb(fto) (2-7 cu ft) Cu Ft. <br /> 6.2,PGII <br /> J UN3291,Regulated Medica+Waste,n o s, TP15 — Z0 Gal TUb (Fath) 42.7 ctf !t)' Cu Ft. <br /> 6.2.PGII <br /> UN3291,Regulated Medical,Waste,n.o s., Cu Ft. <br /> 6.2,PGII TY15 — 20 kcal Tub (Chemo) (2.7 cu ft) <br /> UN3291,Regulated Medical Waste,n o.s., 8iosystme Catdbaa Box (4.2 cu ft) Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n o.s., Cu Ft. <br /> 6.2,PGII <br /> Cu Ft. <br /> Phaemaceuti:ical Waste <br /> 3.Generator's Certification:"i hereby declare that the contents of this consignment are fully and accurately <br /> TOTALS ® O ® Cu Ft. <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 /> Signature � Date <br /> Printed/Typed Name = Phone tt' <br /> 4.TRANSPORTER 1 ADDRESS: / (55x9)275-1121 <br /> h SteciCyci@, Inc. 0 This i9 a Thio 5tlli ettt Applicable Permit Numbers: <br /> 4135 S. Swift Ave Sauter 3400 <br /> n FCesno,CA 93722 t I <br /> N <br /> aTRANSPORTER CERTIFICATION: Receipt of medical waste as described above. -� <br /> Date <br /> t— PrintrType Name Re-AlV C" Signature Phone C 1 1 <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Applicable Permit Numbers. <br /> i air <br /> �J <br /> ;O <br /> �� INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Date <br /> Print/Type Name <br /> Signature <br /> Phone q: <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Applicable Permit Numbers: <br /> ix <br /> �J <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> = Date <br /> Print/Type Name Signature <br /> 7.DISCREPANCY INDICATION <br /> T rtes 1210 : Willi SA Lake,Lff <br /> 9BD.Altemate Facility: <br /> $ E]8A.Designated Facility: 8B.Ahemate Facility: ®BC.Alternate Facility: <br /> IttC. <br /> 4195 W. lAV! 90 PI, t65t O � 2776 .28th CSt. <br /> FresrsO.CA SIMNCO Sol <br /> �$ (US)275-1121 fit)� t A SM <br /> •� Tg�p$T 83� TSiOST 26 <br /> TSKMW <br /> b theapplicable state agency to accept untreated medical wastes and that I have <br /> TREATMENT FACILITY: I certify that I have been authorizedy p <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 GENERA-FUM <br />