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�®Trailer# <br />St <br />ericycle Customer Number: 4421 <br />Receiver # ? <br />MEDICAL WASTE TRACKING FORM Uy INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM <br />1. Generator's Name and Mailing Address 2. Tracking Form Number O <br />U White — GENERATOR COPY: Mailed by Destination Facility to Generator r <br />975 South Faftwout Avmue Blue — DESTINATION FACILITY COPY: Retained by Destination Facility <br />4 CA. 95 L L 0 015 5 8 Green— TRANSPORTER COPY: Retained by Transporter <br />Pink — STERICYCLE COPY <br />4. State Permit or ID No. Z Gold — GENERATOR COPY: Retained by Generator <br />3. Telephone No. (20) 3 ll <br />5. Transporter's Principle Name & Mailing <br />Address <br />Ryder Distribution Resources, Inc. <br />3600 N.W. 82nd Avenue <br />Miami, FL 33166 <br />EPA or State Med Waste ID No. <br />6. Telephone Number <br />(909) 799-8500 <br />7. Transporter Permit or <br />ID No. <br />3124 <br />8. Destination Facility Name & Address 9. Telephone Number <br />STERICYCLE, INC. (909) 799-8500 <br />10390 ENTERPRISE DRIVE 10. State Permit or ID No. <br />REDLANDS, CA 92374 99-00060-P <br />12. Total No. 13. Total Weight <br />11. US EPA Waste Description Containers or Volume <br />A. Regulated Medical Waste S <br />B. Regulated Medical Waste L <br />C. Special Anatomical Waste <br />D. Other <br />14. Special Handling Instructions and Additional Information <br />15. Generator's Certification: <br />Under penalty of criminal and civil prosecution for the making or submission <br />of false sta i sions, I declare on behalf of the <br />generator <br />that the contents of this consignment are fully and accurately described <br />above and are classified, packaged, marked, and labeled in accordance with <br />all applicable State and Federal laws and regulations, and that I have been <br />authorized, in writing, to make such declarations by the person in charge of <br />the generator's operation. <br />�' <br />Printed/Typed Name Signature Date <br />16. Transporter 1 (Certification of Receipt of Medical Waste as described in items <br />11, 12, & 13) <br />Printed/Typed Name Signature <br />17. Transporter 2 or Intermediate Handier <br />(name and address) <br />EPA or State Med. Waste ID No. <br />111AM-.4 <br />Date <br />18. Telephone Number <br />19. State Transporter Permit <br />or ID No. <br />20. Transporter 2 or Intermediate Handier (Certificate of Receipt of Medical <br />Waste as described in items 11, 12, & 13) <br />Printed/Typed Name Signature <br />21. New Tracking Form Number (for consolidated or remanifested waste) <br />22. Destination Facility (Certification of Receipt of Medical Waste as described <br />in items 11, 12, & 13) <br />lk Received in accordance with items y,1, 12, & 13 <br />Printed/Typed Name <br />23. Discrepancy Box (Any <br />initials) <br />24. Other Information <br />0 <br />should be noted by item number and <br />