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<br /> 1.Generator's Name,Address and Telephone Numb,.. :tl
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<br /> CA ?5 U E- 4907
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<br /> CUSTOMER NUMBER j- ti'•_� ..OIL, GENERATOR'S REGISTRATION#
<br /> CONTAINERTYPE 2C. NO.OF 2D. VOLUME
<br /> 2A.DESCRIPTION OF WASTE 2B- CONTAINERS
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately
<br /> TOTALS 1111, Cu I
<br /> described above by the proper shipping name and are classified,packaged,
<br /> edPmark odal d l ball oval governmental rggulations"
<br /> are in all respects in proper condition for transport according to applicable r /
<br /> _Signature / i y Date
<br /> Pnnled/Typed Name - Phone M,r.r
<br /> 4.TRANSPORTER 1 ADDRESS / ~^��
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<br /> tr r ) Date
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<br /> _ 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: !, Applicable Permit Numbers
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<br /> 7.DISCREPANCY INDICATION
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<br /> -} 8C_Alternate Facility: ❑8D Alternate Facility.
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<br /> treated medical wastes and that have
<br /> JJ 9' TREATMENT FACILITY: I certify that 1 have been authorized by the applicable state agency to accept un
<br /> z received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br /> a Date
<br /> Print/Type Name Signature
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