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- MEDICAL WASTE TRACKING FORM NUMBER <br /> d"060 Stericycle• IN CASE OF EMERGENCY CONTACT:CNEMTREC 14IM234.0051 gj <br /> ��"AJPQ <br /> STANDARD MANIFEST 001.10-06•571) Route 2 - 0 <br /> t.Generator's Name,Address and Telephone Number <br /> 111111111111111111111ATTN: loll <br /> 1 <br /> CUSTOMER NuMDER _ 5 Qd ! GENERATOR'S REOISTRATION# <br /> 2A.DESCRIPTION OF WASTE 2e. CONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE,mo.s.,6.2 CONTAINERS <br /> UN 3291,PG 11 857 - 90 Gal Tub (Bio) (12 cu ft) Cu FL <br /> REGULATED MEDICAL WASTE,n.o.s.,62 Til4 _ 44 Gal `Cub (sla) (5.9 Cu ft) <br /> UN 3291,PG II I Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,62 H2k 20 Tal Rub {g16j (8.T Cu 1:t) <br /> Q UN 3291,PG€I Cu Ft. <br /> Q REGULATED MEDICAL WASTE,n.o.s.,6.2, B49 - 37 Gal Tub (Rio), 10.7 L8 (4.9 cu ft) <br /> WUN 3291,PG It Cu Ft. <br /> REGULATED MEDICAL WAST£,(I,o.s.A.2 815 - 20 Gal Tub (Path) (2.7 Cu tt) <br /> W UN 3291,PG II Cu Ft. <br /> REGULATED MEDICAL WASTE.n,o,s.,6.2, 15 - 2D r3a1 Tub (Chutto) (2.7 cu ft) <br /> UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2 t33S _ 26 Gal Tub (Rio) (3.S Cu it)UN 3291,PG 11 Cu Ft. <br /> REGULATED MEDICAL WASTE,n.o.s.,6.2, <br /> UN 3291,PG 11 Cu Ft. <br /> P Rnocaullcal watlo <br /> Cu t <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately TWALS F Cu Ft <br /> described above by the proper shipping name,and are classified,packaged,marked and taWiledfptacarded,and <br /> are inall respects in proper condition for transport according to applicable international and national governmental regulations.' <br /> I , $l Printed/Typod Name Signature Data 7.3 rt-0 Iq <br /> A.TRANSPORTER 1 ADDRESS: Phone#(916) 985 - 5506 <br /> °c STERICXCLE Applicable Permit Numbers: <br /> 11875 White Rock Rd <br /> Rancho Cordova,CA 95742 This is a Through Shipment <br /> a d TRANSPORTER CERTIFICATTO Receipt of medical wasto as described �` <br /> Print/Type Name Signature Date ` s 31.0 T <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone C <br /> Applicable Permit Numbers:INTERMEDIATE HANDLE=R/TRANSPORTER CERTIFICATION:Recut of medical waste as described above. <br /> Print/Type Name Signature Date <br /> j( M 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone#: <br /> rr a It Applicable Pormil Numbers: <br /> I �W� <br /> on INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> a <br /> Printnype Name Signature Date <br /> 7.DISCREPANCY INDICATIONTranSferred Containers, Cu A to : North Salt lake,UT <br /> fWeA.Designated Faciety: 8e.Attemate Facility; 8C.Alternate Facility: 8D.Aftemate FaCD€ty: <br /> CY 1NC. MRICYGL.E.INC. STERICYCLE,INC, STERICYCLE,INC. <br /> U $ ool a rive.Sulu C 136 W.SW ftAvenue 90 North 111 a vveRt 2775 E.26th Street <br /> IX 0.r,t..e.mk.AA 0"77Tease,CA 1Yd722 t40M'So t LAX&.M 04054 Y®l4►Ea11,CA 80()23 <br /> picl)est-471E l 539)275-0994 (e01)936-1555 1323)362.3000 <br /> IEPA# -PA9 IEPA#. <br /> Pit TREATMENT FACfLI rti t I have been authorized by the applicable state agenc t ccept untreated medical wastes and that I have <br /> f- received the abo w iQin accordance with the requirement that ation. A r! <br /> Print/type Name Signature Date Null <br /> coo�Q <br /> ORIGINAL rntF?ZP�t 151k�s 2iN1R <br />