|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> ® Stericycle' ii:CHEMTREC 1-8004241 STANDARD MANIFEST001.10.06-STD
<br /> ®® rroitn yr op,e.nta�ary e:,r: CUSTOMER NO,21132
<br /> l,. tai. "Ii�tal 3tsd"i
<br /> 1.Generator's Name,Address SERVIu.hal IPI
<br /> N a ACCOLN1I 1: 6109749.001 .
<br /> Trit Laza Sur �r Center �r 5� a : ,al. �1 1
<br /> i s s a s.. :':1. SERVILE DALE, 3113113 9:41:03 AM
<br /> a5 DRIVER 10: Roth, Michael
<br /> 5 ;j41PPgM VteL TNT
<br /> r. (114) 2`a.-.:4(84 :>p`t ;i 0131,1,
<br /> JOIN_CtuttlEO: 12.3iA1 CO FT
<br /> CUSTOMER NUMBER $i-1i. i iof (�t�: I
<br /> IRATOH 5 fiEGISTRATION#.:
<br /> 2A.DESCRIPTION OF WASTE 21 Uil?tt.£IV RM? CUM1R RX12
<br /> CxEAA�TZ RX12 OOA00Ufi TBA
<br /> TYPE 2G. NO.OF 2D. VOLUME {
<br /> S 232911 Regulated Medical Waste,n.o.s., � CONTAINERS
<br /> v t-' Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s., Q1't
<br /> Cf
<br /> 6.2,PGII ttA1MAR1(Lwit Type) SL 'sa f t o
<br /> Cu Ff.
<br /> UN3291 Regulated Medical Waste,n,o.s., 4 6.0,
<br /> i c {
<br /> ® 6.2,PGII RXJ2 12 GaJ(Pi�arn),0 Tare tilt
<br /> 1814 44 Gat Tub(Biol, CT 12.7 1 `y14 t,n R t Cu Ft.
<br /> F-
<br /> UN3291,Regulated Medical Waste,n.os., I
<br /> Q 6.2,PGII 011.l((R'/lKtJ401I t: PtlfitOODit�1
<br /> Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s., a
<br /> Z 6.2,PGII Cu Ft.
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> E
<br /> 6.2,PGII a -. i::��«
<br /> s 4' CaFt. .1
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII I Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
<br /> Cu Ft.
<br /> Ft
<br /> 3.Generator's Certification:`],hereby declarer that the contents pI this consignment are fully,and accurately T®TALS
<br /> FL
<br /> described above by the pib'pe+shipping name and y fie tdasss�ied packaged,marked and labelledlplacarded and
<br /> are in all respects in proffer cndition tor�transportCu rding t0 applicable international and national governmental regulations
<br /> s y
<br /> ;'" ;•( 1�..... ...; �`-_.. ! �f ��,�r.�� 4�. � 1!®7 �.i u1C,x Ll���:114....
<br /> PrintedFryped Narhe °'`.t Signatuts' i" ' Date
<br /> sY 4.TRANSPORTER 1 ADDRESS Phone
<br /> }It] j.- rT, APplicabie Permit umbers:
<br /> :6.i 7 r-.s at.T 3 °b t 11.11. .. ..
<br /> a
<br /> TRANSPORTER CERTIFICATION: Receipt of medical waste as described above 7 '
<br /> ac r
<br /> ~ PrinVType Name i Signature -<� Date o
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: :' ✓- Phone#
<br /> N "
<br /> w a Applicable Permit Numbers:
<br /> cc U0
<br /> IU
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATIQN:Receipt of medical waste as described LL L
<br /> cr
<br /> Print/Type Name .Signature` Date
<br /> M in 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADORE S: `. Phone M
<br /> waw Applicable Permit Numbers:
<br /> cc w
<br /> N a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above
<br /> a�E
<br /> F- PrinUType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> � �a# s t �!' _ `+� �1, h mag Lake T
<br /> P F
<br /> �s t 8A.Designated Facility: f 8B.Alternate Facility: ®9G.Alternate Facility ❑8D.Al emate,Facility:
<br /> S,
<br /> Qr yr1,., rS�.
<br /> a�tLJO `may, .
<br /> sLE
<br /> 't`$#'t`t 'V -zf4151,': :4 flet 8 CA .stf3,.i=3t
<br /> z N9
<br /> .1Hs
<br /> g TREATMENT FACILITY: I certify that I have been authorized by the appilcable state agency to accept untreated medical wastes and that I have
<br /> h- received the above indicated wastes in accordance with the.requirement outlined 16 that authorization.
<br /> Print/Type Name Signature Date
<br /> LEAVE ATGENERATOR ::
<br />
|