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--- - MEDICAL WASTE TRACKING FORM NUMBER <br />O + e <br />o•0 5'il�t"�C�/Ci@ IrtOAseoi"EMERGHNCYCONraeT:ctttafhrReei•eoQ-424•s3oD STANDARD MANIFEST 001.10.00-STO <br />'�' FrwaGerFacplo RelydnaRbi Romte #: 124 - 12 CUSTOMER NO. 21132 MDFROOH9HH <br />X <br />Q <br />9 <br />W <br />W <br />15 <br />1. Generator's Name, Address and Telephone NUMber <br />ATTN:Fr:ank Juarez <br />ELMHAVE'H CARE CExM <br />6940 PRCTE'1C AVE' <br />Is7'Ocx' ow, GA 95207- 2602 <br />CUSTOMartNUMUR 6080854-001 <br />2A. DESCRIP710N OF WASTU 25. <br />(209) 477-4817 <br />GENERATOWS REGISTRATION # <br />12/3.6/2015 <br />20. NO. OF VOLUME <br />CONTAINERS <br />UPI329. Regulated hledlcalWaste, moa., TR45 40 Gal Tub (Sia} (8.3 au tt) ('g Ft, <br />6 2, PGI{ <br />UN3$91 Regulated MedlcalWaste, n.aa, T849 - 37 gal Tub (Bid) (4.9 Cu Et) <br />6.2, Foil Cu Ft. <br />UN3291 RegulatedMedPAIWa$(%Mo.s., Tglq _ q4 Gal Tuh(B3p} {5.9 0t1 1r} <br />6.2. PGR .. 0 Ft <br />UN3291, Reaulaled Medical Waste, n os.. 9't321- (13I0) /TP15- (Path) /TY1.5- (Chemo) 20 eill 'Pub (2.7CUPT) <br />UN3291 Regulated Medical Waste, n,o.s., W831- (Bio) /UP3,.- (Path)/WC31- (Chemo) 31 Gal Tub (4.14CUFT OUR <br />62, Poll Regulated medical Wasie, n,o.s., WB43- (bio) /PW42- (Path) /CW43- (Chemo) Gal Tub (5.7CUPx) CU Ft <br />€iN3291 Regulated Medical kyaste.n,o.s., KPB ,. Biosystems Cardboard Box (4.2 au ft) <br />6.2. PGii Cu A. <br />nhralor's CorillIcatloni'l hereby declare that the contents of ttus consignment are full and aCCUI ly TOTALS <br />dvsCrib above by the proper shipping name, and are classified, packaged, marked and lsbelledtplaoard d, and <br />ars In at aspects in properoondihon for transport aocordfng to applicable international and nailona�LRVar monlal regulations" <br />'ZSPiIedfl ed Name _ NQjZjaj <br />,I&N <br />OORTER 1 ADDRESS: <br />Stevioyale, ]Grits. <br />4135 W. Swift Ave <br />rrewno, 0A 93722 <br />of maftal waste as <br />8. <br />Q This is <br />Phone#. (666`}"783-7422 <br />Applicable Permlt Numbers: <br />8auler Reg# 3400 <br />Rate 'W" <br />g. <br />phone : <br />Appticai to Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoelpt of medical virile as desonbed above. <br />PrmVtypa Namo signature Date <br />i e. INTERMEDIATE 14ANDLER 31 TRANSPORTER 3ADDRESS: Phone #. <br />�u Applicable Permit Numbers: <br />hoe Pii <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meciroal Waste as described above. <br />Pdnvlype Name Signature Date <br />Z <br />ua <br />F» <br />0 <br />Transferred _ . _ containers, tau ft to ! Netth Saft Lake, UT <br />OA. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />authorized by the applloable state agency to accept untreated medical wastes and that I have <br />a with tho requirement outlined In that authorization. <br />Date <br />