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• J �� __ --- �� MEDICAL WASTETRACKING FORM NUMBER <br />o®� $ �t'iC�1CI8' STANDARD btANiFESTaot•td•00.37D <br />IN CASE OF EMERGENCY Cbtd'fA07s CHEMFREC 1-8g0•A2A•930g <br />sts°e• haWredPaapie.d",'jc ti' Une,le A. 799 _ R CUSTOMER NO. 21132 mni`R0014R(1f, <br />Generator's Name, Address and Telephone Number <br />ATTN:Irrank Juarez <br />ELMHAVEN CARE CENTZA <br />6940 PACIFIC AVE <br />;xCmmN, CA 95207- 2602 <br />al,n.nne. l•nAnAC J AA -1 <br />III INIIIIIIIIIIIIIIIIIIIIRtlI�IAIIIIRIIIIIIII <br />flamunarnwa RrawrRhmoki @ <br />2A. DESCRIPTION OPWASTE ,. <br />20. CONTAINERTYPE <br />20. NO. OF <br />2D. VOLUME <br />UNulil Regulated Medical Waste, n.as„ <br />6.2, poli <br />TAOS — 40 tial. TUU Bio} (8.3 au ft) <br />CONTAINERS <br />Cu Ft. <br />9t23PeollReQW,atedtdedlglYdaste,n.o,s„ <br />T$A9 . 37 tial !Pub (OW (4.9 OU tt:) <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 /> <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 />r Q <br />:AUTOCLAVE <br />fE <br />REATIt tpj Y�J ¢glJly that I I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received thfre}}tt''above ln�dllcatedd � <br />cies In ccordance with the requirement outlined <br />In that authorization. <br />i <br />PrfnWYpe NX- 7 <br />Signature <br />Date <br />Than tarred containers, <br />cu R to : North Bak Lake, UT <br />1 <br />Wltnl,. <br />ORIGINAL. <br />