|
IYIbL,I\.ML 11-L IftMVt\IItlw I: Vn1Y1 ItlV1Y,uCn
<br />9010 Stericycle' tom`' Tbb,003 �q-8 32 STAN QFri U�a06-STD
<br />PMsoing P-ple. R 6du g Risk' � : 1i0� aM ` .
<br />MW
<br />Of TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print(Type Name Signature
<br />POW O&oM4
<br />I r At IM AT f2Cm.HCiJ A'rg-%M
<br />Date
<br />V1' —,c't°,r- %lAlAt "' %I-ilon=Ami B -L As =lame
<br />1. Generators Na _ (Jre @qq T 1f. Y.&'% CE Oa
<br />Pt''iCl1':is`'• �RtyER . j c
<br />^C17C6'A31
<br />.1700 N CHRISM.N RD $M\M'�� L€'z OR ffiFtRLL� OKI
<br />% CD F�
<br />TRACY, CA9530 � IECjED •
<br />C' gpp
<br />` W COME•• S.
<br />AOS • ?261-91811 1/4/2011
<br />OOa j8�4
<br />•#
<br />CUSTOMER NUMBER f tsps, Re��i
<br />2A. DESCRIPTION OF WASTE 2B• JR57 __ 90 z3a F�R>U 1 VPe 11� I» ,e 2C. NO. OF 2D. VOLUME
<br />p�CK CONTAINERS
<br />UN3291, Regulated Medical Waste, n.o.s., SERV\CE: _ $tet'cy`
<br />6.2, PGII49 ... 37 fY ,j 1Ru 40{ choos Cu Ft
<br />UN3291, Regulated Medical Waste,
<br />n.o.s., Zhan
<br />6.2, PGII TE14 - 44 Gal Cu Ft
<br />jr
<br />UN3291, Regulated Medical Waste, n.o.s., /
<br />TB21 - 20
<br />®
<br />6.2, PGII Gal Cu Ft
<br />QUN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />a
<br />6.2, PGII B15 — 20 Gal Tt �:u f�•7 Cu Ft.
<br />W
<br />_
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />W
<br />6.2, PGII 5 _ 20 , Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6. PGII
<br />Cu Ft.
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► % a Cu Ft.
<br />described above by the prop r shipping name, and are classified, packaged, marked and labelled/placard—, and
<br />are in all respects in proper cnditjon for transport according to applicable international and national governmental regulations"
<br />Printed/Typed.Name Signature t
<br />4. TRANSPORTER 1 + r Phone #:
<br />H
<br />43.35 i4t,Ca Shull Ave. Thi -j is a Through Shipments Applicable Permit Numbers:
<br />i..l
<br />aFresno,
<br />Ca 93322
<br />zN
<br />E
<br />a
<br />TRANSPORTE C-iRTIFICA ON: Receipt of medical waste as describe
<br />~
<br />a. 4 rl( ,_,$ae*•' �v. —�
<br />Print/T eNamet
<br />YP Signature Date
<br />S. INTERMEDIATE HANDLER /TRANSPORTER 2 ADDRESS: Phone #:
<br />Iw
<br />i<¢
<br />Applicable Permit Numbers:
<br />Zia
<br />;W0
<br />°��
<br />z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUType Name Signature Date
<br />a
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />Wo
<br /><
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />is
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION 'Fran C$m$OAers, Cu A to : North Salt L , UT
<br />a ftfttt )CJave
<br />❑ 610rift iwi"eratioii
<br />❑ B fli�iE iDs$19v8
<br />❑ sp 1 8ti&
<br />•, .19
<br />4135 W, SWIFT AVE
<br />90 NORTH 1100 VeST
<br />1345 OW00 DrIVe Ste C
<br />2776 E 26TH STREET
<br />e g
<br />. FIRESNOsCA 93722
<br />NORTH SALT LAKE CITY. UT
<br />Sal Leandro, CA 84577
<br />NON, CA SM23
<br />(568) 275 - OW
<br />(80 1) 996 - 1655
<br />(610)662-1701 •
<br />(323) 362 - 3IO13
<br />g�
<br />i a 31, "t t'OST25
<br />TSIOST22
<br />Cim V Indneratbn PermIN 81-
<br />P-6, P-115
<br />Of TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print(Type Name Signature
<br />POW O&oM4
<br />I r At IM AT f2Cm.HCiJ A'rg-%M
<br />Date
<br />
|