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<br /> � ���� Stericycle IN CMi ,C%,E�'A'Gjj%Y CQNT�V.CHECTRSTOh1E0-42 21732 STANDARD MANIFEST
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<br /> M1.Generator's Name,Address a d?a3ephone Number � lJ�
<br /> 0 ATTN'Crystal Mobno II��II II IEIi�} ify}
<br /> U) �3 VAN TI,OR Rr-K DDS INC
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<br /> (209)823-9218 10M)'2620
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<br /> Cumum Nu 9ER 6084672-001 GENERATOR'S REGISTRATION N
<br /> PA.DESCRIPTION OF WASTE 2g• CONTAfNERTYPE 2C.NO.OF 2D 0. VOLL1h1E
<br /> CONTAINERS
<br /> UN3291,Reguialed Medical Waste,n-o.s... IS",_28 G21 TUb#Bin}43,7 CU ft) Cu F
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<br /> UN3291.Regulated Medical Waste,n-o's.. '549_37 Gal Tub 0a)01 tm R) Cu F
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<br /> Q UN3291.Regulated Medical Waste,n-d.s-. - Cu F
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<br /> EL UN3291,Regulated Medical Waste,n.a-s., Cu F
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<br /> s PGII Regulated Medical Waste,rt,os., 434�_��� 001 T NS-T `CUM Cu F
<br /> UN3291,Regulated Medical waste,n-o.s.,
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<br /> 3.Generator's Ca rti ti catio n:"E hereby declare that the contents GI this consignment are fully and aocu rately TOTALS 1 - Gu F
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/plaearded,and
<br /> are in all respects in proper condition for tranapog aopording to applicable Internallonal and national governmental regulations'
<br /> PrintedlTyped Name t C' '`ti , r
<br /> • , 5 Slgnature Dale --
<br /> S 4•TRANSPORTER T AOD ES Phone N:
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<br /> A+� ThsS �lrougtl � Applicable Permit Numbers:
<br /> Cc Haufcr Rego 3400
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<br /> a TRA NSPflRTER-CE RTI FICATION:Receipl.ol medic4lwaste as d75pedatiove. ;...
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<br /> Print/Type Name__-.. Signafii re __ f Date' -
<br /> 5.IlVTEflMEDIATE HANDLER 2 1 TRANSPORTER 2 ADO RESS: Phone Y:
<br /> Applicable Permit Numbers:
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<br /> z�x INTERMEDIATE HANDLER(TRANSPORTER CERTIFICATION;Receipt of medical waste as described above.
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<br /> Printrrypa Name Signature new
<br /> w 6.INTERMEDIATE HANDLER 3 r TRANSPORTER 3 ADDRESS: Phone N:
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<br /> Applicable Permit Numbers:
<br /> w s a INTERIVIEDIATE HANDLER ITRA NSPt:1RTER CERTIFICATION:Recelpt of rnedmal waste as described ahovo.
<br /> �— Pr1nVTypeName Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Y 0,Designated Facfffly: 68.Anemete Faclllty: Sc.Anarnate rac llity: Lj SD.Altemate Facility:
<br /> 3ir�Mta/ris,Inc,(Attr,afava) Sted-.0e,Inc.tlnctnerator! 3bDrieyt:1e,Inc,jAlstaeIMn Covarrta Marlon.IRe
<br /> U 4136 W.S Ale f 90 N.F04ora Ddva 1551%OIMo Dr4na 49th[!B* 4V*P001 NE
<br /> Kit Frearta,Ci+93722 !�odh Salt Lake.UT Holllctsr,CA 950 3 Brooks.OR 973II6 � �
<br /> t 71337422 (00 171 t96G)M7422 [M5)333-W9€# c0i
<br /> W, fS14fi5 ?? 3144WA-36 TWOS?S3 - Prrrntlt#3164 v Q
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<br /> TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br /> W z a received the above indicated wastes In accotdance with the requirement outlined in that authorization.
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<br /> Prinvfype Name Signature Date Q1
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<br /> Tansloffodas ars._ ►u a: s, rn
<br /> r Trarlsiersad_�ao[r8xlntsra, est#!fta :N_Sal Lake,UT o
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