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MEDICAL WASTETRACKIN3 FORIA NUMBER <br />o"s T <br />{ O ster. c„ y�c�ye, — Jtwwbe of FrI�NGY cONTACTCHENITREC 1.800-424.8300 sTPA15•Q <br />io•oe•sro <br />CUSTOMERN0,211132 <br />!i t, tietierator's <br />NanMjWpj%"T3jjgfW Number <br />i ET&MMIVEH CARL CBWT..MR <br />5940 PAMFIC AVE <br />STOCKTON, CA 95207 2602 <br />(209) 477-4817 12111121115 <br />6090854-00-1CUSTOMER NUMeBR G8R8R TOR'S 11e4ISTRATION B <br />2A. DESCRIPTION OFVrASTE 2S'`�H05 •- 40 Gal Tub (BX ) N(5 3NTYPE 20, NO. cU it} CONTAINER <br />121), VOLUME <br />03291, Regulated 140101 Waste, I „ F, <br />J4 UN3191 Regutatee 1411001 waste, n.o.s., <br />0 8.2, peal T221- (B10) /TRIS <br />UN3291 Regulated Medical Vista, n.o.s., <br />a 2, poll <br />ill UN3291 Regulated Medical waste, n.o.s., <br />� <br />0.2, PQII <br />W UN329 �I Regulated Medlral4Yasle, n.e.s., <br />923POII Regutatad Medical Waste, n.o.s.,i — -- <br />Cu Ft. <br />1 UN3291. Regulated Medical Waste, n e s.. <br />3, Gens at is Certification, 'I hereby declare that tho contents of this mnsfgnmonl are fully and accurately TOTALS ► <br />dos ed ebove by the proper shipping name, and are classified, mwked and labefted/placarded, and g ' J <br />ar in all re.•jj acts n proper condition for trap ort accord)to applicable international and national govarnmeM l re ulaltons <br />V <br />Nr� <br />Print /Ijrped Name sign ure 7VIF tit aaaaaa������ <br />cc 4. T RTHR i "Wif`~ AVG phone #: <br />ECeanofCA 93722 AptaldP�dnit3tg�jsr3g00 <br />�a , <br />a TRANSPORTER C TIFiCATIO a pt of medical waste as descnbad a ova. <br />PdnMpe. Name Signature Data <br />S. INTERMEDIATE HA OLER 2 ITRAN8110RTE 112 ADDR813d Phone #: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as desmbed above. <br />pritiMpa Name Signature Date <br />O. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone #. <br />Applicable Permit Numbers: <br />INT9RUIEDIATE HANDLER ITRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />SI nature Date <br />PItnU']jpo Nemo 9 <br />T. DISCREPANCY INDICATION I rans erre coil B Hers,,,,,,, -------:,CU ft to : NOIrth r-aff lake, UT <br />Z <br />w <br />2 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />TENT FA0IEI�TY11 certffy� ai <br />I have b en authorized by the a}�pfitcabie slate agency to accept untreated medical wastes and that I have <br />therabovveIndicated Wastes In accord 3nce with the requirement <br />outlined In that authorization. <br />Name `c'} �' d.- 'i7 <br />Signature <br />Date <br />r vmaamnr. <br />M <br />N' <br />Cr <br />r vmaamnr. <br />