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oe®� er,Syd <br />• • TrWuf1 sree�fe aawd,4 <br />--_-- -- T----� MEDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF EMERGENCY CONTACT.- CHRMTREC 1.960.424.9304 STANDARD MANIFW0ot•ic-06•STO <br />Route #s 126 ^ 3 CUSTOMER NO. 211132 MDFROOH80L <br />1. Generator's Name, Address and Telephone Number <br />ATTN.Frank Juarez <br />BLIAHAWN CARL" CZNM <br />6940 PAC.TrXC AVE <br />;3'7OCKTON, CA 95207» 2902 <br />CUSTOMER NUMBER <br />2A, DESCRIPTION <br />Ulls29ir Regulated h': <br />I Ut13 <br />6 2, <br />pt; UN3 <br />a 6.2, <br />UNs <br />11113 <br />UN3 <br />6.2, <br />601 <br />6 23 <br />9, <br />6080854--001 <br />;rE 12s. <br />(209) 477-4927 <br />GENERATOR'S REGISTRATION 0 <br />R.o.s„ T805 - 40 Gal Tub (BW (5.3 au ft) <br />n.Os., 'TH49 - 31 Gal. Tub (Bi*) (4.9 cu ft) <br />TB14 44 Gal. Tub(Hi0) (5.9 Ou tt) <br />ma .. I RTf% m103 ., 0Ing I TY C dmo 20 Gal T <br />tded'cal Waste, mo.s., WS31- (Rio) /Wt331- (Bath) /W031^ (Cheme) 31 GAI 'Tub (4.14CUF9 <br />MedtcatWaste,n.o,s., WB43^ (Bio)/PW43- (Bath)/CW43-• (oheme) Gal. Tub(5.7CUPT) <br />MedW Wage, n.o,s., KRR » HiOsYstemS Cardboard Rex (4.2 cu it) <br />MedlWl trlaste, n.os., <br />Certlftcntlon: l hereby declare that the contents of this consignment are fully and accurately ! TOTALS 1► <br />a by the proper shipping name, and are classlfiad, packaged, marked and tabelied/placerda , ar d / <br />da R propor condtl on for transport according to applicable intornalional and notiovigovamm tai regulattoriv � <br />PORTER i ADDRESS: <br />sterioycsie, Inc. <br />�- 4135 V. Swift Ave <br />o°. Prauno, CA 93722 <br />PLC- TRANSPORTE nTIFICAMecetplal <br />c r'4 <br />edleal waste as <br />13 This <br />C. NO. OF <br />CONTAINERS <br />12/4/2015 <br />phoned: tovv/ 104-'r-044 <br />Applicable Permit Numbers: <br />Tfauler Reg# 3400 <br />Date " C�r L <br />— 5. tNTERMEOIATE HANDLER V/TRANSPORTER 2 ADDRESS: `,,J anon s' <br />cm Appl;cablo Permit Numbers; <br />o <br />� <br />INTERMEDIATE HANDLER ITHANSPORTER CERTIFICATION: RoGolpl of medical waste as desodbod above, <br />PrinYTeae Namo - - slanaluro - -_ Data <br />a. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone 9; <br />ac Applicable Permit Numbers: <br />9 INTERMIEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnV Wm Name Signature Date - --- <br />?ESOREPANCY INDICATION <br />Transferred containers, _ OU R to ! With Sak Lake, LIT <br />QA. Designated Feclllty: ❑ 00.Altemate Facility: C] $D,Allemate Facility: <br />`` <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />I <br />agency to accept untreated medical wastes and that I have <br />that authorization. <br />Date <br />