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MEDICAL WASTE TRACKING FORM NUMBER <br />c ®Q Stericycle- 1N CASE OF EM5RQ9NCY CONTACT CHkMTREC 1.800.424-9300 STANDARD &IAN1FEST0ot-10.0&STD <br />aM,t+lnp Propta s,au,kyrr,>r: Route 0: 124 — 12 i CUSTOMER NO. 21 i32 MDFROOHM <br />Generator's Name, Address and Telephone Number <br />ATTHIrxank Juarez <br />ELMHAVLPN CARE CEtt'I.'El2 <br />6940 PACIFIC AVE <br />mcxTgN, CA 96207— 2602 <br />(208) 977-9817 <br />CUSTOMER NUMBER 9000B54_001 QENERAT03%REatsraATION9 <br />2A,D1»SCRtpT10NOFWASTE 29• CONTAINERTYQE 20. NO. OFCONTAINERS CONTAINERS <br />U1t3291 Regulated MedleaiWaste, n.o.s., TB05 — 40 coal. Tub (HIO) (5.3 Cil ft) <br />0.2, PGii <br />U23P61iRegulatedMedica)Waste, s.os., TB49 r 37 Gag, Tub (Bio) (4.9 04 ft) <br />it 603281 RqulaledMedlutWaste!n0.s., Tnja — 44 Gal. Tub(Dio) (5.9 Cui%t) <br />0 6.2, PGii <br />QUN329t RegutatedMedcalWasle.Ro3 TB21—(B3:Q) T1'15—(Ed T 5—(C emo tea 'u C <br />6.2, PGii <br />U�t 603291 Regulated R� foal Waste, n o s , Wg2 ^ (Bio} /t+tP33 ^ {P8t}t} /ttJC31— {Champ) 33 Cal Tub (4 , 3 4C6P ) <br />Us.2, PSlI <br />t:9 8229 R�ulaledModtosWasie,n.os., tdg43—(Bio)/PK43—(Path)/CWd3-(Che.mo) Gal Tub(S.7Cii1=T) <br />U1029t Regulated hiedlulWaste, aos., MW — a:.osystems cardboard J9bx (4.2 Cu. ft) <br />6.2, Poli <br />UPJ328t Regulated hled(cai Waste, ao.s., <br />6.2, PGI <br />i <br />k`, <br />Ito <br />'Cent are fully and accuratelyT®TR i�ethepropclinpopercangoner ental regulationvpod Ntime _ n w fJ rrn SI afar <br />I <br />a TRANS <br />PrinMpe <br />., S. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: 1 <br />�swC3 <br />1� INTERmrzOIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdrimpa Name Signature _ <br />S. INTERMEDIATE HANDLER 317RANSPORTER 3 ADDRESS: <br />o INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of maiicai waste as described above. <br />Print/Typo Namo Signature <br />St;eri0yale, 1110- E] This is a Through shipment <br />4136 W. Swift Ave <br />preanOI CA 93722 <br />CERTIFICATION: RV41061 medical Waste as deson abo <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 /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />thorized by the appllcable sjate agency to accept untreated medical wastes and that I have <br />pith the requirement outline <br />In that authorization. <br />Signature <br />t <br />Date <br />A <br />Vri�uillrHi. <br />I <br />Vri�uillrHi. <br />