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4.i MTREC 1-006
<br /> IN CASE OF EMERGENCY CONTACT1 "0004244MMEDIC SNDARA
<br /> L D WASTACKING
<br /> SIT oot .o3.2Dt NpCNUMBER
<br /> .. Stericyc �e' CUSTOMER NO* 211132
<br /> 1 . Generator's Name, Address and Telephone
<br /> ATTN : Ct•ic Ct'� PAIN
<br /> TU3CAY Dl !-lLYS1C- L7f'1t� iTA ##2il16
<br /> 3112 S I=A1 RMONT AVE 11 /29/2022
<br /> LO , CA 95240- :
<br /> CM40 (209) 369- 5418
<br /> CusTOMERNumsER 605330 31- 00 1 GENERATDR'sREatSTRAWNM
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. Not OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, a,o.s., CONTAINERS
<br /> 6,2, PGI) T ' fFt_ i .ins_ id . fpntAO ? i 4- finnincirmAd t Gt i f"r) Cu Me
<br /> UN3291 , Regulated Medical Waste, n.o.s., to Hf t'l� s~ rrt i �2n .l , 7 f ' t , if Cu Ft.1
<br /> 6,2 , PGII ' 1 - ( int T ' 1 �. , Zl T' ?
<br /> UN3291 Regulated Medical Waste, mos.,
<br /> Q
<br /> 62, 13611 T1 41E;ial T`l494Chenl . l T14P- f n . inwr- el 37 (&iFil Tub 1`4A Cuff . ). Cu Ft.
<br /> q 6U232P9Gii1 Regulated Medical Waste, n,o.s,, slPa2 ( baa t � � n- _ W'1
<br /> 0 G N43- I'Chemol 1N „ } , fPharnil 43 cal . Tui t � / G l 57 1 Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> W 6.2, PGII KR
<br /> lR ( E'io} 0 :31 . Corrugated Box 4 . 32 Cuff , Cu Ft.
<br /> 0 UN3291 , Regulated Medical Waste, n,o.s.,
<br /> 62, PGII Cu Ft
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> 6,2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu FL
<br /> 3. Generator's Certification: 01 hereby declare that the contents of this consignment are fully and accurately TOTALS ► t �j� . Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged , marked and labelled/placarded, and
<br /> are In all respects In proper condition for transport according to applicable international and national governmental regulations"
<br /> Print Name i Signature Data
<br /> 4. TRANSPOBTEFt t ADDRESS: Phone N:( _ 291 " f ' 1
<br /> OC `Stericycle , 11.10 . This IS a fhrotipit (SIiiplliQ111 Applicable Permit Numbers:
<br /> 1075 R A Bridgeford Rd . ' i'SJOST uO
<br /> $� Stockton , CA 95206
<br /> a TRANSPORTER C FiCATION : JtEl�eceipt of medical waste as descri 1
<br /> I a Signature Date � � �� r
<br /> PdnVType Name YI 9 /
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N;
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinUryps Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> cc INTERMEDIATE HANDLER / TRANSPORTER CERTiFICATIONs Recelpt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7, DISCREPANCY INDICATION
<br /> i
<br /> B/ Dpstpr d .Fsciir : i _ SfA. nc / ..'• r , ! nc hoinerator) tBliA8 , IriC l�� i1toOave) vert, r1nsn n� iIf c
<br /> -_+ 7075 R1 A * ` 90 N . Foxboro Dfi�le 2776 C . 210th St, 4860 DrooW Ike Road WE
<br /> tl�l�
<br /> V s ttcD ANorth Salt LBI1 e , UT 84054 Vernon , CA 9Q051t Broohs, OR 97305
<br /> k � 1
<br /> '[19 294-7114 801 930- 1 i 71 8815 783; 7122 505)3@3-0880
<br /> a m i; O (W 3 0 21)22 'A-ti4 > (•1r't- 3D Perri i W � r3z1
<br /> I W
<br /> TREAT NT FA TY: ti that' l ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> EW receive2o=4=tes in ccordance with the requirement outlined in that authorization .
<br /> Printfrype Name Signature Date
<br /> t
<br /> URIUINAL
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