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®: OreleRlny PteDle alounng.,.. � gj, \' F 3 <br /> 1.Generator's Name,Address ani Teft?P ne Num <br /> ¢ia <br /> t 1.aFt ct>3a n <br /> 600-.1 LOU= ST <br /> STOG °ICag. CN 952t?6- 4907 <br /> GENERATOR'S REGISTRATION b VOLUME <br /> 2C. NO.OF 2D- <br /> C ,b CONTAINERTYPE CONTAINERS <br /> CUSTOr,7EP NUMBED 28. Cu Fi <br /> 2A.DESCRIPTION OF WASTE <br /> UN3291.Regulated Medical Waste, <br /> nOS. S °s t cu <br /> 6 2.PGII <br /> nos. .17 C 1 4 'Bio i4.9C'M tt �. Cu <br /> UN3291,Regulated Medical Waste, T8 <br /> 62,PGII t5. r,t2 <br /> ftl <br /> UN3291.Regulated Medical Waste,n o s. 44 Pal T'tnb ngr� 9 Cu F <br /> 62,PGII t <br /> UN3291,Regulated Medical waste,nos. TB2I _ ,.1F Gal. 14,11:0 i_rr} 4 - ° ='7 t�' Cu <br /> 2 6 2,PGII <br /> = sr^,thl 7.7 f t:i <br /> 11 UN3291.Regulated Medical Waste.n o s• Pp15 20 4iA 1, Cu F <br /> Z 62.PGII r T <br /> 'at UN3291,Regulated Medical Waste,n o s. n . Cu F <br /> `=f 6 2,PGII , y <br /> r a <br /> UN3291,Regulated Medical Waste.n o s. Cu F <br /> 6 2,PGII <br /> UN3291.Regulated Medical Waste,n o s Cu F <br /> 6 2.PGII <br /> ETO=TALS ct,1 <br /> ully <br /> nd accurately <br /> 3.Generator's Certification:"I hereby <br /> declare that the contents of this consignment <br /> marked and tlabelaled/placarded,and <br /> described above by the proper shipping name,and are classified,packaged, <br /> tc Ilcable international and national governmental regulations <br /> are in all respects in proper ondition for transport according to ZIP Date <br /> t Signature Phone p <br /> Pnnted/Typed Name try``a 1 'j 5 <br /> r1 4 TRANSPORTER 1 ADDRESS' T 9 8 9 tt 92h i 3 <br /> fy h-iPmOtt't Applicable p&%), N3rfibers. <br /> w Sts ci--^-.10. Iter. Aau3.et Ft�r�iC 3$Ut} <br /> 48:35 2_ Swift 5t <br /> CC Ta Q A -2' <br /> lc�rsno r� <br /> a a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. pate <br /> a: Signature Phone <br /> ~ Print/Type Name <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS <br /> • ApphCaDle Permit Numbers <br /> uW <br /> D5W <br /> Lw0 <br /> n W= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Date <br /> r— Signature <br /> hone d <br /> Prinu type Name P <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS <br /> Applicable Permit Numbers <br /> w <br /> �aW <br /> O <br /> 3213 <br /> ¢a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICAT{ON: Receipt of medical waste as described above <br /> Date -- <br /> F y Signature <br /> c z PrinvType Name e� <br /> 7.DISCREPANCY INDICATION CU 11111* Sat LAV,`A a <br /> T t U SD Alternate Facility <br /> r ®BC.Alternate Facdity- <br /> g a8.Alternate Facility: _ <br /> BA.Designated Facility 'rjt&n �Iet.Iry- <br /> SW <br /> 5 26th Sit <br /> j tric q t t fear � verr ion,CA, 9M$ <br /> _ <br /> 035W. .9t mUr OW4om <br /> t Ipft�tsr.CA t 23 <br /> (3 �30-3=1 <br /> Is'r�ww.CA 93722Lam (83t)83fi►-1M <br /> (' q S�t 553 �.88 TgJd9 q'-26 <br /> L 3� t 3}2t6t tit 36 <br /> Thi OST'22 <br /> fl <br /> Ilcable state agency to accept untreated medical wastes and that I have <br /> TREATMENT FACILITY: I certify that I have been authorized by the app <br /> = e received the above Indicated wastes in accordance with the requirement outlined In that authorization. Date <br /> Signatare <br /> Print/Type Name <br /> �d R <br />