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®e► �, �o le.Aaeinin R16, j11t9:6 1#: .5�1 j.3 CUSTOMER NO.21
<br /> r
<br /> I.Generator's Name,Addrebs'and Telephone Number
<br /> A'PTN:Brit.an Hanson
<br /> 3RI 3uneIGIAL
<br /> 61801 LOWZ ST
<br /> STOCK. il, mk 95206- 4907
<br /> 209) 982-5199 8l16/2013
<br /> CUSTOMER NUMBER 601 095-002 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B- CONTAINERTYPE 2C. NO.OF 20. VOLUME
<br /> CONTAINERS
<br /> UN3291,Regulated Medical Waste,n o.s., AU Gal duh C13aoy (5-3 cu ft) Cu Ft.
<br /> 62,PGII THOS -
<br /> UN3291,Regulated Medical Waste,n.o.S, Cu Ft.
<br /> 6.2,PGII TB49 - 37 Gall T%lb (;l iO) t4,9 ";'u ft} r
<br /> UN3291,Regulated Medical Waste,n.o.s.. TBl4 - 44 Gal Tula(bio) (y 9 Cu ft) Cu Ft.
<br /> O 6.2,PGII
<br /> i" UN3291,Regulated Medical Waste,n o s, TB21 _ 20 Gal Tub(,Brio) {2.7 cu ft} Cu Ft.
<br /> Q 6.2.PGII
<br /> 2
<br /> LL! UN3291,Regulated Medical Waste,n.o s, T,P15 20 Gal Ttll7 (Pact]} i2,7 Cu t t} Cu Ft.
<br /> Z 6 2,PGII
<br /> W UN3291,Regulated Medical Waste,n.o s.,
<br /> 62,PGII TY15 - 20 Gal Tub tCA Io) (2.7 cu ft:.) Cu Ft.
<br /> 6 2,PGII Regulated Medical Waste,n.o.s, KRB _ BfoSys,t:eas Cardboard Box (4.2 cu ft' Cu Ft.
<br /> UN3291,Regulated Medical Waste,n o,s., Cu Ft,
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> PharMaCeUtiCal fiR66te
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately
<br /> 7TO=TALS < 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 -
<br /> Phone#: (559)7,,,7y_j 1l l
<br /> cc 4.TRANSPORTER 1 ADDRESS:
<br /> This is a Through Bt11pffitselt Applicable Permit Numbers:
<br /> W $terit yCleo Inc.
<br /> = a 4VIS W. Swift: Ave ,` . Haulat: Reg# '34OU
<br /> o° Fiesno,CA 93724/
<br /> Z< TRANSPORTER at 4cei of me al waste as described above
<br /> cc 1 �. ` Date
<br /> ~ Pnnt/Type Name`A Signature .� Phone#
<br /> S.INTERMEDIAT HANDLER 2/TRANS 0 R AD RESS: Applicable Permit Numbers:
<br /> W
<br /> Q 2
<br /> O J
<br /> W G
<br /> w= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. .
<br /> Signature Date
<br /> Print/Type Name Phone#
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Applicable Permit Numbers'
<br /> ¢_¢
<br /> U,J
<br /> 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br /> Ui_ _Date
<br /> ? PrintlType Name Signature
<br /> 7.DISC PANCY INDICATION
<br /> tisrMd famammt Cg a to = Nodh Safi Lake,UT
<br /> BB.Alternate Facility: ®BC.Alternate Facility:
<br /> ❑80.Alternate Facility:
<br /> BA.Designated Facility: ❑
<br /> g riGyclQ,Inc
<br /> g StertcyPcte Inc. Inc. Ie,Inc. a�s2775 E.26M St
<br /> 4156 W. AV* St]N, miam t 8;1 DI'ty e
<br /> Naath Sat Lake.L r 84 Vernon, 2- 91It13t3
<br /> >:nasno,CA SCi722 H0�1 � 953 (323)362"30
<br /> E� (WS)275-t 121 (Sal)93&iws c 1096 TS10 I'T 26
<br /> TSIOST2a 3A.448," TSIOST 83
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to 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 /> Punt/Type Name
<br /> Signature
<br /> c �
<br /> LEAVE AT GENERATOR
<br />
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