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CUSTOMER NO.21132 4ii il.i-•,t•i re <br /> 1.Generator's Name,Address and Telephone Number <br /> A'S"t'td:ii i �Irt ffd;it?.'.• it �� � � �� <br /> ilii �•,rta�tIP'$P.I. <br /> 001 1X*1WLr ST <br /> •t . 4"' <br /> 5TH Y_'K']t?'[�, �'h ! - ' •`, <br /> CUSTOMER NUMBER C•I��,Q�t)r�J'002 GENERATOR'S REGISTRATION# <br /> CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERS <br /> UN3291,Regulated Medical Waste,n.os, q ,4 44, i:4i T,Ab !b' •! 1'1 = '� Cu F <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n o s, T64 g T i;;; Ttiat: i$1 i 4 Cu F <br /> 6 2,PGII + <br /> CC UN3291,Regulated Medical Waste n o s, TH14 - q q •s:�; ".;! 'S2 ` s f T' + Cu F <br /> O 6 2.PGII <br /> Q UN3291.Regulated Medical Waste.n o s, TV I 0 s Cu F <br /> 62.PGII <br /> W UN3291,Regulated Medical Waste,nos, gig - 2:;i a� rut:• ;t",sCru t r ��1 Cu F <br /> Z 6 2,PGII <br /> F3J� Cu F <br /> UN3291.Regulated Medical . , I 't_ i ,_Nl <br /> 62,PGII <br /> -• <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 /> �'lIACBtdG�'UC1Ct1 fid�C? •_ - <br /> Cu F <br /> 3.Generator's Certification:-1 hereby declare that the contents of this consignment are fully and accurately <br /> TOTA�SP�' � + - Cu F <br /> described above by the proper shipping name•and are classified,packaged, <br /> internationalmark nd labelled/placarded, <br /> ab ll d/pl al Bove nman al regulations" <br /> are In all respects in proper condition for transport according to app <br /> Pante irryped Name Signature <br /> Date ' <br /> Phone If <br /> 4.TRANSPORTER 1 ADDRESS Till,5 i y y '#t.: ::e. ,"e:rscarc' Applicable Permit Numbers. <br /> w �. 53.:5.s F..g .in i It=•= <br /> Ca <br /> � 41_'••95 B. 'a'.d3fft L <br /> as <br /> to `�• <br /> CL < TRANSPORTER CERTIFICATION: Receipt of medical waste as described above - <br /> OC r L Date <br /> Print/Type Name Signature <br /> Phone# <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Applicable Permit Numbers <br /> `+w <br /> L Q Q <br /> wW <br /> W a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above — <br /> Date <br /> _ PrintlrypeName Signature <br /> Phone# <br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS Applicable Permit Numbers <br /> a <br /> o� <br /> LQ= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br /> w Date <br /> I <br /> Print/Type Name Signature <br /> 7.DISCREPANCY INDICATION TFaS'S CU ff>D h Sia Lakk_ QJT <br /> �' . <br /> = 80 Alternate Facility: <br /> 8B.Alternate Facility: 8C.Alternate Facility: <br /> �. �BA.Designated Facility: <br /> t^. <br /> 1113 <br /> startcKli3 - may, ♦ I�.•�Z SanAftL�.-`11$'Sit$ <br /> 4135 W.`7NM St 90 ' 1�Wd b 11� H f� rirt•i �'•�.11'r r �.!i�:,=. <br /> a Frrs o.CA 93722 raar8tr►-50 Lal•e, $4,154 <br /> .�;a .� .. •:l'l, <br /> z <br /> (559)275-1124 <br /> it3t31�3iFrt� S rrt3t� ?STZ_ <br /> �S p. ! <br /> i = <br /> ju TSIOST22 <br /> applicable state agency to accept untreated medical wastes and that I have <br /> it0authorization. <br /> TREATMENT FACILITY: I certify that I have been authorized by the app 9 Y <br /> received the above indicated wastes in accordance with the requirement outlined in that <br /> � Date_ <br /> Print/Type Name Signature <br /> LEAVL All ERATOR <br />