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i.Generator's Name,Address and Telephone Number ti 4f <br /> ' •B c a an H-iiirt. 6 4 <br /> 1�TTt�e ( t <br /> ri f. fi ll"I rI AL <br /> Eta O 1 I.01� ST <br /> 3V..,KTOV, CA 9524);.. 4a137 <br /> r� <br /> 6016095-002 GENERATOR'S REGISTRATION# <br /> CUSTOMER NUMBER CONTAINER TYPE 2C, NO.OF 2D. VOLUME <br /> 2B CONTAINERS <br /> 2A.DESCRBPTION OF WASTE Cu F <br /> UN3291,Regulated Medical Waste,n o S. 1Ht: - 411 (,,Al Iinfo fax-) <br /> 6 2,PGII t Cu F' <br /> UN329t,Regulated Medical Waste,n o s. TBr14 J+ t3Qt Trac 1 Pit <br /> 6 2,PGII $ Cu F <br /> C UN3291,Regulated Medical Waste,n o S. T814 4; Gal 3'ti#�f L)::1 t`•f u �'j <br /> 62.PGI1 17-7 u #t; Cu <br /> 2 UN329t.Reguiated Medical Waste.n o S, <br /> 'Yt321 - 2t1. ' <br /> g 6 2,PGIItr t <br /> Cu F <br /> J1 UN3291,Regulated-Medicat Waste,n o S. T�1.5 :%tI �a 1 atY r�'+L711 <br /> Z 6 2,PGII Cu F <br /> W UN3291,Regulated Medical Waste,n o s, r1S _ �'!1 1?4.1 Tub <br /> t i <br /> 6 2,PGII Cu F <br /> UN3291,Regulated Medical Waste•n o S, <br /> 6 2,PGII Cu F <br /> UN329t,Regulated,Medical Waste,n o s. <br /> 6 2,PGII C'.F' <br /> f�a1a cma�euf.t•:AS ipih ste <br /> TOTALS ► c.F <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment <br /> n marked are tully beaed//placarded and <br /> described above by the prnd accurately <br /> oper shipping name.and are classaccording <br /> to a packaged, t <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations" i <br /> �r Date <br /> Signature <br /> Printed/Typed Name <br /> 4.TRANSPORTER 1 ADDRESS- Th!s .1 1 i tMr"WTts tStrr"p •T• Applicable Permit Numbers <br /> Q JLe3'1.iL ��•�', �n':. ,� i jl�'.t�==t I,r..ra f j,,,• <br /> LU <br /> 4133 6i- SW-tCIL <br /> ft :i IL <br /> L Ch <br /> 4 TRANSPORTER CERTIFICATION: Receipt of medical waste as described abode. <br /> L Datecc <br /> t r <br /> � v, �.� y,• •i Signature Phone# <br /> PrinUType Name �/ P <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORT 2 ADDRESS. ' Applicable Permit Numbers <br /> rW <br /> !@rt <br /> :O J <br /> im= INTERMEQIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Date <br /> z Signature <br /> Print/Type Name Phone# <br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Appt Cable Permit Numbers <br /> haw <br /> � <br /> i <br /> Q 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described a ove <br /> w Z <br /> Date <br /> i r Signature <br /> Z Prrnt/Type Name <br /> 7.DISCREPANCY INDICATION Tramiwfw , It to I Raft Sal LAO.UT <br /> Ti <br /> Facility. ❑BD Alternate Facility. <br /> 88.Alternate Facility: <br /> _ I 8A.Designated Facility: ":1e bx 1 <br /> 3 �� 9tartCyClc4.list- Sterkycta.InC San.Ari�::,tc <br /> 4136 W.SoVIR St SO 1I+]f$It 1100 Vern Ch errlon.Ch avai. <br /> t wftt+:°;eft L13kh,Lir o �:•t;Vis. <br /> FrewwC,�t937,22 i6Ut}91 6 e +SS 362- 17(36%376-1124 T'�t'�_"9 T^?��''T `r <br /> U TWISM22 ' '..i�-9�, <br /> u 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 /> Pnntlrype Name Signature <br /> LEAVE ERATOR <br />