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<br /> 1.Generator's Name,Address andTeiephone Number
<br /> }kTTN-.8rtrait ayt3Cit1
<br /> .SRI St.MGICIAL
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<br /> STOI_ICTt-iit, f_'A, 95201 491}? tiCI9) �$i-5 99 4f`6tze'I
<br /> n rlQ ...^a.' GENERATO •S REGISTRATION#
<br /> CUSTOMER NUMBER {0 10 j- CONTAINER TYPE 2C. NO.OF 2D. VOLUMFr
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERS
<br /> UN329t,Regulated Medical Waste,n o s.. Cu F1
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<br /> UN3291,Regulated Medical Waste,n.o.s, , s.• Tutr (Dif�) (4- 4 •:'� F$; Cu FI
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<br /> CC U111,13291,Regulated Medical Waste,n o s. to)4 _ 44 Gal Tlztt ter.°? (5-9 +_tP E�?
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<br /> !Q UN329t,Regulated Medical Waste,n o s, 7@21 - 213 Gal Tri t BCC i(°9 i T r_<a ft? Cu FI
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<br /> UN3291,Regulated Medical Waste,no s., /r y1°p lyy 42.7 a IllCu FI
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately
<br /> TOTALS ► � '.'� � Cu FI
<br /> lacarded,and
<br /> described above by the proper shipping name,and are classified,packaged,ablinternationainand national governmental regulations',
<br /> are in all respects in proper condition for transport according to appI
<br /> Signature -
<br /> i� Date
<br /> Printed/TyPed Name hers t 59) x?-y- »T.
<br /> 4.TRANSPORTER 1 ADDRESS: r This is a T 011,411httZrimerltt: Applicable Permit Numbers:
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<br /> a 1,.- Freanio�CIA 937224.1:35 H. swift: St Fulec Rei 34ti0
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<br /> CL Q TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 1 � �
<br /> tom- /? Signature 1 Date
<br /> Print/Type Name , Phone-# 1 1
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS, yy Applicable Permit Numbers:
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<br /> nx W a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br /> i
<br /> __ Signature Date
<br /> Printf Type Name
<br /> Phone#:
<br /> W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS, Applicable Permit Numbers:
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<br /> a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Date
<br /> i Z Prini Name Signature
<br /> 7.DISCREPANCY INDICATION
<br /> T _ ._.. _ '111 t*: Salo L.*te,UT
<br /> �BAT.Designated�Faclflty: ❑86.ARemate Facility: ❑8C.Alternate Facility: ❑8D.Alternate Facility:
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<br /> si kv . atc .Int. 1 Dt 2775 .2W S4.
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<br /> 4135 W.S'Y S3 M Nem t ak ,CA 1 23 Vernon.CP. 9t7n52
<br /> .. Freww CA 93M Novfh S`aft I slti9•rtJT S4 831 63&-1(898 !3231�-3WO
<br /> e (W)275-1121 (80t)9,36-1565 1�#P 93 •?f V0 g r6
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<br /> JTREATMENT FACILITY:I certify that i have been authorized by the applicable state agency to accept untreated medical Wastes and that I have
<br /> I� received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Date
<br /> Print/Type Name
<br /> Signature
<br /> E AT EN L;
<br />
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