Laserfiche WebLink
qiKiwamw 06- <br />MEDICAL WASTE TRACKING FORM NUMBER <br />® *A Stericycte' IN CASE OF EMERGENCY CONTACT: CHEMTREC 14W4STANDARD nso <br />FEST oot•ro.MS <br />' °"�'a"°1 `�`"'' �� CUSTOMER N0.21132 N D FAR DO ME Y N1 <br />t. Generator's Name, Address and Telephone Number <br />an n <br />ATTN : 1 I <br />GOLDEN LIVING HYPANk - 565 <br />4545 SHSLLEY COURT <br />S -11, CA 95207 <br />:.www• .+a% ww.ea A.i. l+fA1� <br />UN3291, Regulated Medical Waste, <br />GEmERATows REOWRATM If <br />CONTAINER TYPE <br />T921 - 20 Gal Tub(Bio) (2.7 cu ftp <br />� 6.2. PGII ....__.._ ..---•-- ..�-_, ..._._., <br />?1)(O2 C <br />i <br />3. Generator's Certification: •I hereby declare Oast the contents of this Consignment are fully and accuratelyTOTALS 10.described above by the proper shipping name, and are classified. packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations! <br />i <br />PrintedlTyped Name 2' (�Oc�ft `J Q2' SI Lure A &=6 <br />2C. NO. OF <br />CONTAINERS <br />20. VOLUME <br />2A. DESCRIPTION OF WASTE <br />UN3291, Regulated Medical Waste. <br />"e'�� + ���'Y'C[ <br />6.2. PGII <br />y <br />'JShwkyde <br />UN3291, Regulated Medical Waste, <br />Date <br />6.2, PGII <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />UN Regulated Medical Waste, <br />0 <br />PGII <br />Q <br />1.1143291. Regulated Medical Waste, <br />w <br />6.2, PGII <br />W <br />UN3291, Regulated Medical Waste, <br />2 <br />6.2. PGII <br />W <br />UN3291, Regulated Medical Waste, <br />@x <br />L+ w <br />6.2. PGII <br />UN3291, Regulated Medical Waste, <br />GEmERATows REOWRATM If <br />CONTAINER TYPE <br />T921 - 20 Gal Tub(Bio) (2.7 cu ftp <br />� 6.2. PGII ....__.._ ..---•-- ..�-_, ..._._., <br />?1)(O2 C <br />i <br />3. Generator's Certification: •I hereby declare Oast the contents of this Consignment are fully and accuratelyTOTALS 10.described above by the proper shipping name, and are classified. packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations! <br />i <br />PrintedlTyped Name 2' (�Oc�ft `J Q2' SI Lure A &=6 <br />2C. NO. OF <br />CONTAINERS <br />20. VOLUME <br />Cu FL <br />Cu Ft. <br />"e'�� + ���'Y'C[ <br />Cu FL <br />y <br />'JShwkyde <br />Cu Ft. <br />Date <br />Cu Ft. <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Cu Ft. <br />Stwicycle Inc -Atbdm <br />Cu Ft. <br />Applicable Permit Numbers: <br />Cu FL <br />F <br />3 . <br />Cu Ft. <br />Cu Ft. <br />Print/Type Name Signature <br />4. TRANSPORTER 1 ADDRESS: Phona C <br />Stericycie, Inc. This iS t_ ugh Shipmen@ ppikxble Per k.5t u um baars:rs: 21 <br />4135 Rmt Swift Ave.CL Hauler Reg# 3400 <br />IL ¢ <br />� <br />Fresno Ca 93722 <br />TRANSPORTER CERTIFICA'>tION: Receipt of medical waste as descr' above. <br />"e'�� + ���'Y'C[ <br />8 !2 <br />y <br />'JShwkyde <br />PrintlType Name Signature <br />Date <br />n <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone N: <br />Stwicycle Inc -Atbdm <br />11 <br />Applicable Permit Numbers: <br />to <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />1345 a C <br />Print/Type Name Signature <br />Date <br />ee6. <br />INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone u: <br />@x <br />L+ w <br />Applicable Permit Numbers; <br />t <br />9H4 <br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />(323'} 362 - 3044 <br />g <br />' FEB 4 8 2C 6C <br />TS31fTsrOST2s <br />Print/Type Name Signature <br />Date <br />, <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical <br />Wastes and that i have <br />7. DISCREPANCY INDICATION <br />E <br />Tmotemdcwtaimm, • eu It to , Narth Sall Lake, UT <br />y <br />'JShwkyde <br />W Oastgnatad Facility: 80. Alternate Facility: <br />8C. Alternate Facility: <br />80. A Fasaay: <br />Inc -Athodave Sb3doide Ina- Incineration <br />Stwicycle Inc -Atbdm <br />Steficycle Inc -Aukodm <br />to <br />4135 W. SVWFTAYE 90 NORTH I IW <br />1345 a C <br />2775 E 28TH STREET <br />W <br />FRESNO. vED Z N SALT LAKE CITY, <br />� CA 94677 <br />VERNON, CA 90023 <br />(559) 275 - I I2f (Bal) 936 - 1555 <br />(510) 562 - 2177 <br />(323'} 362 - 3044 <br />' FEB 4 8 2C 6C <br />TS31fTsrOST2s <br />Tsr r 26 <br />, <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical <br />Wastes and that i have <br />received the above indicatedtwaste n a nc ditfNi1equirement outlined in that authorization. <br />PrintlT Name -Signature Date <br />