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®®® Sterecycle* .0..t-, a a.vev en..e.....d.o...d.,• --.-� <br /> p1mam"ft ie.R.".9VIA, 1 CUSTOMER NO.21132 50520200 <br /> u <br /> i.Generator's Name.Address and Telephone Number <br /> ATTN:Brian Hanson UNION <br /> SRI SURGICIAL <br /> 6801 LOQ ST <br /> STOCRWN, Cal 95206- 4907 <br /> (209) 482-5199 <br /> CUSTOMER NUMBER 6016075-002 GENERATOR'S REGISTRATION If <br /> 2A.DESCRIPTION OF WASTE 28• CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> CONTAINERS <br /> UN3291,Regulated Medical Waste,n o s., T805 - 40 Gal Tub (8101; (5-3 eu ft) Cu t <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste.n O.S. T049 - 37 Gal Tub (Vio) (4.9 Cu Lt) Cu Ft. <br /> 6 2.PGII <br /> UN3291,Regulated Medical Waste,n.o.s., T014 44 Gall Tub(SiA) (3,9 Cu it) i Cu Ft. <br /> O 6 2,PGII <br /> Q UN3291,Regulated Medical Waste,n o.s., T821 - 20 Gal Tub(Bio) (2-7 Cu ft) Cu Fc <br /> 6.2.PGII <br /> W UN3291,Regulated Medical Waste,n o.s., TPlg - 20 Gal Tub (Path) 42.7 Cu it) Cu Ft. <br /> Z 6.2,PGII <br /> W UN3291,Regulated Medical Waste,n o.s.. Cu Ft. <br /> 6.2.PGII TY15 - YO tial 7!ttb (Crh o} (2.7 Cid ft) <br /> UN3291,Regulated Medical Waste,n.os, FCRH _ ViosystMe Cardboard 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 /> PbarMaceuttica3 Mast>R Cu Ft. <br /> �•Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately <br /> TOTALS III- 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" I r <br /> Signature G '!- Date <br /> Printed/Typed Name Phone#: (559)275 11�1 <br /> 4.TRANSPORTER 1 ADDRESS: Applicable Permit Numbers: <br /> CC paa <br /> StBCiC�C14t, lite. this is s lhetnt_ 41.35 V. Swift Atte 777 <br /> Hauler Reqs 3400 <br /> zCL <br /> Frtsstao,rA 99722 I <br /> i < TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. / 3 <br /> �� <br /> ~ Pnnt/Type Name <. ' Signature <br /> Phone#: <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: 1 Applicable Permit Numbers, <br /> �isW <br /> UJI_j <br /> IND <br /> iuZ= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> i Date <br /> Print/Pype Name Signature <br /> Phone#: <br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Applicable Permit Numbers: <br /> lax <br /> W J <br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> cc <br /> = Date <br /> = Printlrype Name Signature <br /> 7.DISCREPANCY INDICATIONT Noft SO`aft.UT <br /> ou ft to <br /> 8A.Designated Facility: �88.Alternate Facility: ❑ <br /> 8C.Altemate Facility: ❑60.Alternate Facility: <br /> Shwkycle,Inc. otic. <br /> 4135 W.S�Avco 90 PI � <br /> 1561 thm 2775 .216M St. <br /> "00 go MIM Vernon,CA WM <br /> Fnt✓Ilno 1 (eel) ' (831)MOST 8 (M) 3MD <br /> 09)3sm TSIOST-26 <br /> A"36 <br /> x <br /> Ur <br /> Pat TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that have <br /> creceived the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> e Date <br /> Print/Type Name Signature <br /> r VE AT G ERATOR <br />