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<br />Stericycle' IN CASE OF EMER(
<br />Protealng People. RedUCIng Risk: t 3
<br />itor's Name, Address and Telephone Number
<br />i pK!., j -lui1en
<br />M1 _Ralio �_
<br />rp y EAjctN ,4;TEr_1AL1TY
<br />47 W -EKWN AVIS
<br />TrT,zAt:,Y, CA 9S3796
<br />ICY CONTACT: CHEMTREC 1-800-424-9300
<br />CUSTOMER NO. 21132
<br />(209) 830-4062
<br />6.2, PGII
<br />UN3291, Regulated medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />p1jarmac-eutic,*1 Waxyt4
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled
<br />are in all respects in proper condition for transport according to applicable international and,natior
<br />I'Vi
<br />X Printed/Typed Name L SJ__
<br />SERVICE RECEIPT
<br />ACCOUNT 11- 6076382-036
<br />SGMF Tracy Eaton Speciality AM
<br />SERVICE DATE: 10125111 8:12:20
<br />DRIER 10: RB1
<br />SH I pp I NG 00CMENT V. R00 JUS
<br />TOTAL COLLECTED; 0
<br />TOTALS 1111*'
<br />il regulations."
<br />SUMMARY(Cont Type) QTV
<br />DRIVER- Blythe, Rusall
<br />FREQUENCY: On Cal I
<br />NEXT PICKUP: 1/1100
<br />CUSTOMER SERVICE:
<br />Thank You for choosing Stericycle
<br />VOL
<br />CF
<br />4. TRANSPORTER 1 ADDRESS:C] rnis is a �jLlhrough Sbipmemt Phone#:
<br />Ir 11 Applicable Permit Numb rs:
<br />413E, WROV Swift .Ale- Hauler N 3400
<br /><0 I I /I i
<br />2 0. � a
<br />j
<br />FE Z
<br />(L 4
<br />medical waste as described above.
<br />5. INTERMEDIATE ATE HANDLER 2 /TRANSPORTER 2 ADDRESS"
<br />�cW8
<br />M INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z
<br />Hx
<br />f� — Print/Type Name Signature
<br />U, 6. INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />0
<br />Date
<br />Phone
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />7. DISCREPANCY INDICATION * i'm % minststh 0*11t I m- U-1
<br />CUSTOMER NUMBER 6076382-036
<br />GENERATOR'S REGISTRATION #
<br />8A. Designated Facility:
<br />2A. DESCRIPTION OF WASTE
<br />2B.
<br />8D. Alternate Facility:
<br />Inc -A6todam
<br />C) 12
<br />4135 W, $WFTAVE
<br />CONTAINER TYPE
<br />1345 CkM Ste C
<br />Son Loar**, CA 94677
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />U.
<br />T657
<br />90
<br />G141 Tub
<br />MW (12 CU ft)
<br />Z 3
<br />Z -Z
<br />Uj
<br />6.2, PGII
<br />3A448 -A -W
<br />T531frVOST25
<br />T310ST-A
<br />—,ru
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T1349 '":31
<br />(441 Tub
<br />(, 5 (7FTS tt)
<br />81,5
<br />6.2, PGII
<br />TREATMENT FACILITY: I certify
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />I!_
<br />xeived the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />M
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Signature
<br />TE14 -
<br />44
<br />GalTUMR�10(5
<br />9 CU
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TU771
<br />-TU
<br />il
<br />uu ttt
<br />62, PGII
<br />Cc
<br />W
<br />UN3291,, Regulated Medical Waste, n.o.s.,
<br />Tsl 5 -_20
<br />Oal TUb
<br />Q
<br />( Pat Ill . 7 TH u�
<br />— ( 2 ,
<br />Z
<br />6.2, PGII
<br />Wtt)
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />5 -
<br />-2ri
<br />ua'1 Tub
<br />(CheAO)
<br />6.2, PGII
<br />UN3291, Regulated medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />p1jarmac-eutic,*1 Waxyt4
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled
<br />are in all respects in proper condition for transport according to applicable international and,natior
<br />I'Vi
<br />X Printed/Typed Name L SJ__
<br />SERVICE RECEIPT
<br />ACCOUNT 11- 6076382-036
<br />SGMF Tracy Eaton Speciality AM
<br />SERVICE DATE: 10125111 8:12:20
<br />DRIER 10: RB1
<br />SH I pp I NG 00CMENT V. R00 JUS
<br />TOTAL COLLECTED; 0
<br />TOTALS 1111*'
<br />il regulations."
<br />SUMMARY(Cont Type) QTV
<br />DRIVER- Blythe, Rusall
<br />FREQUENCY: On Cal I
<br />NEXT PICKUP: 1/1100
<br />CUSTOMER SERVICE:
<br />Thank You for choosing Stericycle
<br />VOL
<br />CF
<br />4. TRANSPORTER 1 ADDRESS:C] rnis is a �jLlhrough Sbipmemt Phone#:
<br />Ir 11 Applicable Permit Numb rs:
<br />413E, WROV Swift .Ale- Hauler N 3400
<br /><0 I I /I i
<br />2 0. � a
<br />j
<br />FE Z
<br />(L 4
<br />medical waste as described above.
<br />5. INTERMEDIATE ATE HANDLER 2 /TRANSPORTER 2 ADDRESS"
<br />�cW8
<br />M INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z
<br />Hx
<br />f� — Print/Type Name Signature
<br />U, 6. INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />0
<br />Date
<br />Phone
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />7. DISCREPANCY INDICATION * i'm % minststh 0*11t I m- U-1
<br />�xr��L �ac�
<br />8A. Designated Facility:
<br />E] 8B. Alternate Facility:
<br />8C. Alternate Facility:
<br />lA
<br />8D. Alternate Facility:
<br />Inc -A6todam
<br />C) 12
<br />4135 W, $WFTAVE
<br />90 NOFM i 100 VWST
<br />1345 CkM Ste C
<br />Son Loar**, CA 94677
<br />2M 2M MEST
<br />VERNON CA SM23
<br />U.
<br />MRESMCA 93722
<br />1121
<br />OTH SALT LAKE CITY, UT
<br />NOR
<br />(001) 936- 1566
<br />(610)662-2177
<br />(3231362 - -30DO
<br />Z 3
<br />Z -Z
<br />Uj
<br />�559) 275 -
<br />TWOSTrA
<br />3A448 -A -W
<br />T531frVOST25
<br />T310ST-A
<br />TREATMENT FACILITY: I certify
<br />that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />I!_
<br />xeived the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />PA�frr M-
<br />Signature
<br />Date
<br />�xr��L �ac�
<br />
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