Laserfiche WebLink
®O Stericycle, <br />® • y waftme <br />0 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />[N CASE�OF$EM Y CONTACT: CHEMTREC 141111"24 STANDARD MANIFEST ats•1o�STo <br />RDiit CUSTOMER 140.21192 MDFROOB`'SW <br />2M2 ORIGINAL <br />r• <br />1. Generator's Name, Address and Telephone Number <br />GOLDEN LIVING HYPANA - 569 <br />4545 SHELLEY COURT <br />STOCrMN, CA 9S207 <br />(209) 477-0271 1/4/201. <br />6080856-001 <br />CUSTOMM Mumma GENEAAmmftW nnoNi <br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF <br />21). VOLUME <br />Regulated Medical Wade, mo.s. TW7 - 90 Gal Tub (Bio) (12 Cu ft) CONTAINERS <br />6_� 11 <br />Cu Ft <br />LINMRegulated Medical Wye. 0.04, TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />6.2 PGII <br />Cu FL <br />®UN3291, <br />3 Regulated Medical Waste. mo.s., TB14 - 44 Gal Tub ( r o) (5.9 u ftp <br />6.2, PGII <br />1 ! Cu FL <br />Q <br />UMMIi Regulated Medical Waste, n.os. - 20 Gar 1 au <br />it <br />Cu Ft <br />W <br />UN3291.Regulated Medical Waste, n.os., TB1 - 20 Gal Tub (Bath) (2.7 Cu ft) <br />6.2, PGII <br />Cu Ft. <br />1Z <br />5 <br />UN3291, Regulated Medical Waste, n.o.s 7Y1 S - 20 Gal Tub ( Chemo) (2.7 cu ft) <br />6.2. PGIB <br />Cu FL <br />UN3291, Regulated Medical Waste. n.o.s.. _ _ _ _ <br />- <br />_ _ <br />6.2, PGI1 - - — — - - <br />Cu Ft. <br />UN3291, Regulated Medical waste, n.os., <br />6.2, PG11 <br />Cu Ft. <br />Bharmaceut cal. Mas <br />Cu Ft. <br />t -7 <br />3. or's Certification '1 hereby declare that the contents of this are fully acarratefy T®TAL$ 10 3 6 % • { Cu Ft <br />described above by the proper slipping name, and are ctassitled. packaged. marked and ed, a <br />are in all respects in proper ition for transport ao`cording to applicable international and national governme ragulati o <br />t ra <br />Printed/Typed Name CM kS' re Date <br />4. TRANSPORTER 1KESS: �--t Phone e: C559)27.5-1121 <br />�L°eracycle, Inc. This is a u Shipment Applicable Permit Numters: <br />stx <br />9135 t Swift Ave. <br />< R <br />Hauler # 3400 <br />Fresno,Ca 93722 <br />CA <br />a Zq <br />TRANSPORTER of medical waste as described above. <br />~ <br />QC�ER,.TIFICAl10N:::Receipt <br />�i <br />` �✓ Y . W m� j T 2 <br />PdnV yps Name ` �^ ' + Signature Date <br />5, INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone C <br />115 <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meclical waste as described above. <br />PdntlType Name Signature Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 9: <br />cc <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />- <br />PrinVryps Name Signature Date <br />7. DISCREPANCY INDICATION .(ranstemd erS, cut to: North Saft Lahr UT <br />y <br />F=- <br />00. DeafFacility: 88. Altenuft Facility: 6C. Alternate Facility: SD. Altsrnate Facift: <br />Stericycto Inc -Autoclave Stericycle Int- Indnerakm StInkyde I nc -AullocIrie Stwlqde Inc -AuWcbw <br />4135 W. SWIFT AVE 90 NORTH 1100 WEST 1345 DOOM Orlve Sts C 2775 E 26TH STREET <br />FRESN0,CA 93722 NORTH SALT LAKE CITY, UT SanCA 77 VERN . CA MW <br />(559) 275 - 1121 (l01) - 1555 (510) 552- 2177 (3231362 - 30M <br />TWOST22 3A 3b TS31)TS -216 <br />ISA ipj� <br />TR TMENT FACILITY: ! °certify that I I 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 ! ` 1 1� R R S tore Date <br />2M2 ORIGINAL <br />r• <br />