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0 <br /> ®�� �.�••.a"" Ute SUA - 23 CUSTOMER NO.21132 I^fur 13`�var!:c•R' <br /> ®® FmIMlnR P(opte flrdgdnR R4R <br /> 1.Generator's Name,Address and Telephone Number <br /> AT'ITN:iI Haresort _ <br /> SRI SiWGICIAL <br /> 6001 LOQ: ST <br /> STr <br /> 6016095-002 GENERATOR'S REGISTRATION It <br /> CUSTOMER NUMBER CO{4TAINF.R TYPE 2C. NO.OF 2D. VOLUME <br /> 2A.DESCRIPTION OF WASTE 2B. r CONTAINERS <br /> UN3291.Regulated Medical Waste,n s, pet55 - 40 Gal Tub <br /> tf3ira9 t� � CU 1<1) Cu FI <br /> 6 2.PGII i CL Cu FI <br /> f*) <br /> UN3291,Regulated Medical Waste,n o-s, T649 ---j <br /> Z?.. a13. T►sla dBi+a� t4. <br /> 6 2,PGII <br /> UN3291,Regulated Medical Waste,n o.s, 'FBi�- 4 da3l ��tb(✓3&a�� i <br /> Lt) Cu FI <br /> O 6.2,PGIIf' UN3291,Regulated Medical Waste,n.os, Gag rub iBa1 �' tf Cu F+ <br /> Q 62,PGII <br /> p[ Cu FI <br /> LU UN3291.Regulated Medical Waste,n o s 9'>si5 - 241 a3 TeAO ;Pac t {z' 1,ti ) <br /> W6 2,PGII rU t 4 <br /> UN3291 Regulated Medical Waste,n o.s., TVIS - AU alai Tub 4C'h ,'s ZF Cu FI <br /> 6 2,PGII <br /> UN3291,Regulated Medical Waste,n os, �_ _ siovyyt ews t.asalbaard Hr a ,�• '' �*s €t) Cu FI <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n o s, <br /> Cu FI <br /> 6.2,PGII <br /> Cu Ej <br /> piIAFBfdC�etE>MSCd•I i�dSt'f+ <br /> TOTALS ► �� Cu F <br /> 3.Generator's Certification:"I hereby declare that the contents of this <br /> consignment <br /> are marked and idly a d/placuiami and <br /> described above by the proper shipping <br /> name,and are classified.packaged, <br /> e in all respects in proper condition for transport according to applicable international and matiortaMeiovernmental regulations" <br /> \\ Date ~c <br /> Priltledlryped Name ' Phone tt: <br /> 4.ft ANSPORTER 1 ADDRESS: T&iis is a Thr«ezpt". 8foipmertt Applicable Permit Numbers: <br /> a steirfcwle, Ite+ <br /> > 413 9.r Swift 3t Haulwc Ftesyfg 3�I? <br /> a jCCe*a*,GA 93722 <br /> aN r <br /> a TRANSPORTS C RTIF TION: ec t of medical waste as described ve. <br /> Dat <br /> ~ Printlrype Name Signature <br /> Phone>t. <br /> _ 5.INTERMEDIATE ANDLER 2/ RANSPORTER 2 ADDRESS: <br /> Applicable Permit Numbers: <br /> �W <br /> L 4 QW <br /> S W J <br /> z W= INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> CC i_ Date <br /> x PrinVType Name Signature <br /> Phone>l <br /> W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Applicable Permit Numbers: <br /> waa <br /> Q W J <br /> y s a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> w <br /> Z z Signature Date <br /> Cc- Print/Type Name <br /> ~ 7.DISCREPANCY INDIGATION- CSI 111 to : NWIh Sal Lake,UT <br /> 8a.Alternate Facility: ®8C.Alternate Facility: E]8D.Atternate Facility: <br /> }, A.Designated Facility: terir,, 'Cie,III <br /> F_ SIIZT794 LE.26th St <br /> .J..I_" <br /> 9.I'99C �t>arlCy ,Bnti4135 W.Silia . <br /> Ereene.CA 83722 84054 "CiZ t r^3 IM4 Irl.CA. 9011`.8 <br /> Imo. (50)293-91211 (got)1 is" � (0311 IW t�3t 367-3M <br /> Z T a>3. - T xSfUS .8 <br /> 4 E <br /> W TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> cc <br /> received the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> Print/Type Name <br /> Signature Date <br /> R <br />