Laserfiche WebLink
MEDICAL WASTE TRACKING FORM NUMBER <br />Of Sterlicycle° IN CASH OF Eh1ER43ENCY CONTACT: CHEMTREC 1.600.424.9300 STANDARD MANIFEST 001-10.08sTD <br />®.P Prot,d4"I R"NI Route #. 124 ^ 19 CUSTOMER NO. 21132 MD ROOHAKK <br />i. Generator's Name, Address and Telephone Number <br />ATTN:Frank Juarez 1 j[ <br />MOM= CARI9 CBNT.SR <br />6940 PACXFXC AVE <br />swcxTON, CA 95207- 2602 <br />209) 477-4317 12/23/2015 <br />CUSTOAInR NuhlaER 01 OENrERATOR'S REGISTAAMOR 4 <br />2A. DESCRIPTION Or WASTE 28. CONTAINERTVPE 20. NO. OF 20, VOLUME <br />UN3291 Reguated Medical Ydasta, mo.s., CONTAINERS <br />6.2, Poll THOS -- 40 eat Tub (Sio) (5.3 Cu 1:t) Cu Ft <br />g2PGI1Re9ntatedMkdIcalWasle,n.os., TH49 _ 37 Gal Tub (Bio) (4.9 ou tt) Cu FI <br />p &2, Polf Regulated MedtcaiYdasie, n,o.s., TB14 ® 44 Gal Tub {Sia) (5.9 qu tt) Cu Ft <br />82,1`61 Regolaled Madical4Yasio, n.o s„ T321— (ala) /Tt?15— (Path) /TY15- (Chemo) 20 dal. Tub (2.70t1Lt) Cu Ft <br />ts1 <br />UN3291Reguialed Medical Ylaste, n.v.s„ <br />W 6.2,POIS W1331^ (Hi9)/W>?31^ CP41th)/WC31^ (Chemo)31 Gal Tub (t1.14CU T} u Ft. <br />®23PGI MI Regulated AiedlalNlaste,n.o,s., i+t1343r ala)/1?Wb3—{patls)ICwb3^(Chemo) Gal Tub(5.7CUFT) Cu Ft. <br />UN3291 Regulated Merica: YWaste, nos,, <br />6.2, PGiI mm sJo stems Cardboard sox (4.2 at: £t) Cu Fl <br />UN3291 Regulated Medial 1Yaate, n.os,, <br />6,$ PGIf Cu F! <br />Cu Ft <br />3, norator's Carilflcationt h hereby declare that the contents o1 this consignment are fully and accurst TOTAt»$ i C Cu Ft. <br />dQ cn d above trj the proper sh'ppang name, and are classified, packaged, marked and iabe}ted/placard ,and <br />a041711kespocts, to proper condition for transport according to applicable international and national mental rogulak ns" <br />IP odflypedName Sr at &0-93-6 <br />PORTER 1 ADDRESS: Phone fl: (866) 783--7422 <br />Ut Stericyal,e, Xna. Q This is d Thcough 5 melnt: Applicable Permit Numbers, <br />4135 W. Swift Ave <br />Hauler Reg# 3400 <br />0 <br />aR Fresno,CA 93722 <br />ILI TRANSPORT RTIFICATI , ecelplot medloatwaste as desa92::: <br />PrtntPlype Namo Signature Data <br />6. INTERMEDIATE HANDLER /TRANSPORTER2ADDRESS. Phonelf. <br />Applicable Permit Numbers <br />INTERM50JATR HANDLER (TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrtnViypo Name Signature Date <br />M 6. INTERMEDIATE RAN DLER3/TRANSPORTER3ADDS VSS: Phone 9. <br />1h� Ap*able Permit Numbers: <br />s <br />INTERaY u ATI~ HANDLER /TRANSPORTER CERTIFICATION: Reoetptol medtcal%vaste as described above. <br />0PrinViy'peName Signature Date <br />1. DISCREPANCY INDICATION <br />Transfarred tomainers, era !t 10 : With Sal lake, LIT <br />A. Dostgnalod F+,cliltyt eta. Alternate Facillty: [] 80. Allumato FAoility; ❑ 8D. AIlernate Faa}Itiyr <br /> <br /> <br /> <br /> <br /> <br />fnVP)po <br />ATMENT ff� ' �rti 4ha a been authorized by the applicable state agency to accept untreated medical wastes and that l have i <br />I.- <br />ved # e�Er yAN V es,aorotance tvdh the regturement Du#fined #n that au horizatton. <br />Name �f4 Slgnnture Data <br />ORIGINAL <br />