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- �--- —� — — — — — - MEDICAL WASTETRACKING FORM NUMBER <br />•�+ 124 a STANDARD MANIFEST 001-10.0"70 <br />p • 1 S'�e�`j �t r�,Ei !N CASE OF EMERGENCY CONTACT; CHEtdTREC t-800-024.8304 <br />i ®a•{Route d <br />Prc9KL.gProPMGA,[c&gtS,L' ts: ^ 13 CUSTOMER NO, 21132 MDEROOH7LP <br />w <br />a us$ <br />a <br />. Generator's Name, Address and Telephone Number <br />ATTN:Frank Juarez <br />E MHAVJ I CARE CEMR <br />6940 PAC11ric AVS <br />S'S{)CA'1'0211 CA 95207- 2602 <br />(209) 477-4017 <br />Cuesot.+an Nuatasn 6080854-001 GanEaAToR'9 REGISTRATION 6 <br />12/2/2016 <br />2A. DESCRIPTION OF WASTE 28, CONTAiNERTYPE 20. NO. OF 21). VOLUME <br />UN3201 ReouiafedMedlcalwaste, Mos„ TB05 - 40 (gal Tub 03W (5.3 ant f7;) CONTAINERS <br />6.2, 1`611Cu Ft. <br />6 23291 Republad MedfcalWasta, n o s.) TB49 - 37 Gal Tub WO) (4, 9 4U, tt) t <br />UN3291 Regulated Mealcalwasla,n.o.s., T'B14 - 44 qac, Tt.1b(Dio) (5.9 Cu ft) (� % <br />6.2. pAl1 <br />Male Medicals gal Tul)(4.14CUF, <br />Mata Medical WasI9, It as., wBO3- (Bio)/PW43- (Pat h) /CW43- (Rhemo) Oax Tub (5.70UFT) <br />dated Msdica! Waste, n o.s., Kni _ Biosystems Cardboard Bax (4.2 au ft) <br />ulaled fdedlcal Wasta, n,o.s. <br />tore Cerilticationi "I hereby declare that the contents of this consignment are fully and accurately TOTALS <br />above by the proper shipping flame, and aro ciassilled, packaged, marked and Iabelecilpfacarde , and <br />aspects In proper condtflon for transport according to opptieabts fnternatonat and national go mental regutatrons" <br />i ADDRESS: <br />Steeci.6yC3.e, TitC+ ® TUB d. <br />4135 19. Swift Ave <br />ri res3no,CA 93722 <br />of madleat waste as <br />6. INTERMEDIATe HANDLER 21 TRANSPORTER 2 ADDRESS: <br />N <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as desuibed above. <br />PrinUlype Name Signature <br />M 6. INTERMEDiATE HANDLER 3 /TRANSPORTER S ADDRESS: <br />iNTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION, Receipt of medical waste as described above. <br />Pdnvtype Name Signature <br />9 <br />CS <br />i t< t V 6 Cu Ft. <br />L . Date ~ R <br />Phone 8: V GG <br />Applicable Permit Numbers: <br />.Hauler Reg## 3400 <br />Phone 0: <br />Applicable Permit Numbors <br />Pato <br />Phone #- <br />Apptkable Permit Numbers: <br />Doto <br />CREPANCY INDICATION <br />r Transfttrrotl bontalnors,. ou It 10 , North Soft Luke, UT <br />Desipnatad Riot?. ORD. Altemate Facility: ❑ 8C. Aifomatc Facility, <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />authorized by the applicable slate agency to accept untreated medical wastes and that I have <br />) with the requirement outlfned In that authorization. <br />Date <br />