COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

9/24/2810 16:48 Remote ID Imprint ID s • ®®® StericyclW OF EMERGENCY CONTACT: CHEMTREC A. '2A1 - 1? 1. Generator's Name, Address and Telephone Number ATTN.- Caroline Jackson WAGNER HE1GHTS N IRSING 9289 BRAKSTETTER PL REEMILITATION CEIrM STOCIMNI CA 95209- 1700 2B. GENERATOR,s REotsTRAnoN # CONTAINER TYPE TH49 - 37 Gal Tub (Bio) (4.9 Cu ft T514 - 44 Gal Tub(Bio) (5.9 Cu tt) TE21 - 20 Gal Tub(Rio) (2.7 cu ft) TB15 - 20 Gat Tub (Path) (2.7 cu t _ D 4/1_8 MEDICAL WASTE TRACKING FORM NUMBER STANDARD MANIFEST DOt-10.06-STD 2C. NO. OF 2D. VOLUME CONTAINERS 3. Generator's Certification: "I hereby declare that the ovnients o`this consignment are fully and accurately I TOTALS 1110- described described above by the proper shipping name, a re ssIliad, packaged, marked and labelled/placarded, and are in all respects in proper condition for trans po ng app!cable international and national governmental re ula ns." \ i IPrinted/rypedName -twi NGa Signature Date cc 4. TRANSPORTER 1 ADDRESS: _ - - 'Phone #:r5 �`) 275 _ 0 m St.ericycle, IRC. Applicable Permit umbers: s a 4135 West Swift Ave. This is �Z Fresno Ca 93722 Z< TRANSPORTER CERTIFIdATIIONN: Receipt of medical waste as described above. ~ Print/rype Name T&-,� V. +� Signature Throigh shipment S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: / o� wo INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date Phone #: Applicable Permit Numbers: Date w 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: a o Applicable Permit Numbers: 8� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date ' 7. DISCREPANCY CUSTOMER NUMBER _6r 2A. DESCRIPTION OF WASTE 8A. Designated Facility: UN3291, Regulated Medical Waste, i .2 6.2, PG I I UN3291, Regulated Medical Waste, 4135 W. SVMFTAVE 6.2. PGII UN3291, Regulated Medical Waste, 6.2, PGII Q ® UN3291. Regulated Medical Waste, Q W 6.2. PGII UN3291, Regulated Medical Waste, Z 6.2, PGII W UN3291, Regulated Medical Waste, 6.2, PGII UN3291. Regulated Medical Waste. ! TREATMENT FACILI t�ertify that I have been authorized by the applic 6.2, PGII UN3291, Regulated Medical Waste, stes in accordance with the require.Lo 6.2, PGII 2B. GENERATOR,s REotsTRAnoN # CONTAINER TYPE TH49 - 37 Gal Tub (Bio) (4.9 Cu ft T514 - 44 Gal Tub(Bio) (5.9 Cu tt) TE21 - 20 Gal Tub(Rio) (2.7 cu ft) TB15 - 20 Gat Tub (Path) (2.7 cu t _ D 4/1_8 MEDICAL WASTE TRACKING FORM NUMBER STANDARD MANIFEST DOt-10.06-STD 2C. NO. OF 2D. VOLUME CONTAINERS 3. Generator's Certification: "I hereby declare that the ovnients o`this consignment are fully and accurately I TOTALS 1110- described described above by the proper shipping name, a re ssIliad, packaged, marked and labelled/placarded, and are in all respects in proper condition for trans po ng app!cable international and national governmental re ula ns." \ i IPrinted/rypedName -twi NGa Signature Date cc 4. TRANSPORTER 1 ADDRESS: _ - - 'Phone #:r5 �`) 275 _ 0 m St.ericycle, IRC. Applicable Permit umbers: s a 4135 West Swift Ave. This is �Z Fresno Ca 93722 Z< TRANSPORTER CERTIFIdATIIONN: Receipt of medical waste as described above. ~ Print/rype Name T&-,� V. +� Signature Throigh shipment S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: / o� wo INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date Phone #: Applicable Permit Numbers: Date w 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: a o Applicable Permit Numbers: 8� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date ' 7. DISCREPANCY 0128 ORIGINAL tt1 R QQ' INtarth Salt LaKfl_ Akemate Facility: Stericyde Inc Autodave 1345 DoollWe DrIve Ste C San Leandro. CA 94377 (510) 562 - 1781 Klass V Inineration PermV 9 80. Alternate Facility: Ster)tyde Inc -Autoclave 7775 E 26TH STREET VERNON, CA 90023 (323) 362- 3000 P-6, P-115 State 17y to accept untreated medical wastes and that I have ld I uthorization. Date AUG 2 81010 rm 8A. Designated Facility: 8B. Alternate Facility: i .2 Stericyde Inc-Autodanre SGarityde irm- incineration 4135 W. SVMFTAVE 90 NORTH 1100 WEST ' FRESNO,CA 93722 NORTH SALT LAKE CITY, UT 76-0994 (601) 936 - 1555 TS31, TSIOST25 TSIOST22 c � ! TREATMENT FACILI t�ertify that I have been authorized by the applic = received the abov ' cat stes in accordance with the require.Lo Print/Type Name G Signature rl 0128 ORIGINAL tt1 R QQ' INtarth Salt LaKfl_ Akemate Facility: Stericyde Inc Autodave 1345 DoollWe DrIve Ste C San Leandro. CA 94377 (510) 562 - 1781 Klass V Inineration PermV 9 80. Alternate Facility: Ster)tyde Inc -Autoclave 7775 E 26TH STREET VERNON, CA 90023 (323) 362- 3000 P-6, P-115 State 17y to accept untreated medical wastes and that I have ld I uthorization. Date AUG 2 81010 rm