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•e• Sterlcye:le' °tlyf{4ttLr3. ;�Slep ®. ye �CUSTOMERNO.2113 FiFROO ,60A <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Brian Hanson <br /> 6801 LOMM ST <br /> STOC'RTow, CA 95206— 4907 <br /> {2ti9) 9>3:�-•5199 9I13/2l_113 <br /> CUSTOMER NUMBER 6016095-002 GENERATOR'S REGISTRATION# <br /> CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> 2A.DESCRIPTION OF WASTE 23• CONTAINERS <br /> UN3291,Regulated Medical Waste,n o.s, TB0.5 - 40 Gal Tub ( a►) (5.3 Cu ftp Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste•n o s.. T049 - 37 Gal Tub ($i0} (4.9 cu ft) Cu Ft <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste•n os, TB14 44 Gal Tub(Bio) (5.9 Cu ft) � r Cu Ft <br /> o 6 2,PGII Zu 44-1^ <br /> I" UN3291,Regulated Medical Waste•n o-s. ° Cu ft Cu Ft. <br /> Q 6.2.PGII <br /> W UN3291,Regulated Medical Waste,n.o s., TP35 20 Gal Tub (Path) (Z-7 LII .tt) Cu Ft. <br /> Z 6.2,PGII <br /> W UN3291,Regulated Medical Waste,n o s., Ty25 - 20 Gal Tub (Chemo) (2.7 Cu tt) Cu Ft. <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste.n o s. KR8 - Bio9ystenas Cardboard Box (4.2 CIA ft) Cu Ft- <br /> 6.2,PGII <br /> UN329t, gulated Medical Waste,n os, Cu Ft. <br /> 6.2.PGII <br /> Ph aiceulitate Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately <br /> TOTALS 111- <br /> 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 /> � �Date <br /> r.� L4br tom__ Signature �` 'C^ — <br /> Printed/Typed Name Phone#. (559)275-1121 <br /> 4.TRANSPORTER 1 ADD A�S S: This is a Through shipment <br /> C � elcic +C�e, Ince Applicable Permit Numbers: <br /> 41.35 81. Shift A®e Hauler Rao 3404 <br /> =a Fresrti 93722 <br /> �,..... <br /> r Z TRANSPORTER CBATIFICATI Race pt d(medical waste as descrided above. " <br /> S Date <br /> ~ Print/Type Name ttY SignatuJe $'f'' <br /> Phone#: <br /> 5.INTERMEDI E DL R 2/TR TER 2 ADDRESS: applicable Permit Numbers <br /> i¢¢ <br /> U, <br /> W0 <br /> ce a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Date <br /> z Signature <br /> Print(Type Name <br /> Phone# <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Applicable Permit Numbers. <br /> <_¢ <br /> C J <br /> e INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> W x Date <br /> z Print/Type Na Signature <br /> 7.DISC ANCY INDICATION ou Il to Lake,1ff <br /> Tranaftrndv <br /> 8B.Alternate Facility: ®8C.Alternate Facility: <br /> E]IID.Alternate Facility: <br /> BA.Designated Facility: {d@,Inc. <br /> iswkycle.Inc. Slerlcy*-Inc. steftycle.�•bn 011" 2775 E.266% <br /> g 4135 W. Atte 90 N.FOUM 00" WWI <br /> i F'rsfano,GA 93'f22 N00 UT ,CA SM <br /> M�t1t7n.GA <br /> S3i 13�p-4Q56 (moi)362-3M <br /> (5m 275.1121 {fit} '3555 ( } -26 <br /> P1 <br /> TSIOST22 <br /> i <br /> - TREATMENT FACILITY: i certify that I have been authorized by the applicable state agency or accept untreated medical wastes and that I have <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 />