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®® vmua�ng hoate Reduaxg wu � w~ w " ,. <br /> si.Generator's Name,Address and Telephone Number <br /> • - •iart E{artsc.ra <br /> sm 4 t1RtOIC Y 7�L <br /> 61301 W <br /> JIGE ST - 49Ct-t <br /> STOC�'Li N, CA i:tl 2; qac-51?t! ''/ 1'+� •-'I` ' <br /> ,60-16095-00"�- GENERATOR'S REGISTRATION# VOLUME <br /> CUSTOMER NUMBEq CONTAINER TYPE 2C. NO.OF 2D <br /> CONTAINERS <br /> NE <br /> RIPTION OF WASTE 2B' CuF <br /> gulated Medical Waste,n ci s, YW 5 - 4r} Ga<1. 'PtBf+ � Lt.?�; yrr, grCuF <br /> gulated Medical Waste•n o s. T84977Cal YTS+ tt31{'# l 9 rig � CuI <br /> gulated Medical Waste.n o s. 'TV14 44 Cat Tib 06 .s10 r_;A ft. Cut <br /> Q UN3291.Regulated Medical Waste.n D s <br /> YB2X - max t+$1 Yxth{sa'�.aa ;?.? <br /> ti 62.PGII +¢'bZh? :L7.7 ::u tri Cul <br /> W UN3291,Regulated Medical Waste,n d s, gp�y Zk1 Gal TuI� <br /> W62,PGII Cul <br /> U2, (3a.1N3291.Regulated Medical Waste,n o s, nr4 ij •• .j (3a.1Tvb41, t- ' c O f t } <br /> 0 62.PGII Cu <br /> KRH_ - Bir,nry `an c'ar.dtsa,m[d t3rrv. R4.2 r tit €t) <br /> UN3291,Regulated Medical Waste,n o s. Cu <br /> 6.2.PGII <br /> UN3291,Regulated Medical Waste•n o s. <br /> 6 2,PGII Cu <br /> Phartnacc+utiCal Kast+e <br /> TOTALS ► cl, <br /> 3.Generator's Certthe proper Ishipping name,candtthe contents are class f ed�pacfkagedsignment are m <br /> marked andllabelled/placa ded,and <br /> described above byacable nternat onaI and national governmental regulations" �. 7 r f <br /> are in all respects in proper condition for transport according to app Date <br /> CC _Signature <br /> Printed/Typed Name <br /> This -is .1 •ifi.C'�i t hu.p=@I;tr• Applicable Permit Numbers <br /> cc4.TRANSPORTER f ADDRESS �j,a_ 1tU'. �LaZF,C Fy,�'� x•1t1U <br /> gtr�iClltyi= r <br /> y¢ 4135 9, Sill <br /> cc d I'CH'Sttr?r�•A 93722 +r t <br /> CC Q TRANSPORTER CERTIFICATION' Receipt of medical waste as described above <br /> Date <br /> cceA Signature Phone# <br /> F- PnnVType Name <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS /� Applicable PermitNumbers <br /> i 11 <br /> V w 1 <br /> uQw ,.. <br /> 0 <br /> wo <br /> W= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Date <br /> a Signature <br /> Print/Type Name Phone# <br /> �w <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Applicable Permit Numbers <br /> u`rw <br /> [W J <br /> Z`3 INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Date <br /> LU z Signature <br /> 'a <br /> i z Print/Type Name <br /> UT <br /> 7.DISCREPANCY INDICATION Cil IX�A : ft�al�' ' <br /> BC.Alternate Facility: BD Alternate Facibly. <br /> = 8e.Alternate Facility: ^swriq `1Q,Inc. <br /> 8A.Designated Facility: ❑ <br /> nr. 1551 � 2?T5 E.25th k <br /> E� �•k1c_ g0 fwdtaro Or I,.IoWro,CA W23 vemon,CA 90068 <br /> E 4135 VN. t AVO Nod LekV.� 13231362-3000 <br /> y Freslno,CA 913722 (Sol)936-1953 T all <br /> TSIOSf-26 <br /> E� ( s)a7�-rear <br /> .0TSIOST'22 <br /> a gs <br /> L4x U- <br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that have <br /> received the above Indicated wastes in accordance with the requirement outlined in that authorization. Date <br /> � Signature�-- <br /> Print/Type Name <br /> t ' <br /> UFAVE <br /> AT GENERATOR <br />