Laserfiche WebLink
MEDICAL WASTETRACKING FORM NUMBER <br /> ®p StericyCie° SE OF EMERGENCY CONTACT:CHEMTREC 1.800.424-9 STANDARD MANIFEST 001-10.06-STD <br /> • PcnlectingP.gle ecdudngAM' Raia'ta #: 026 - E CUSTOMER NO.21132 MDFROOGGAL <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Lix Peixeira (! }! <br /> LA SAT,ETT'E CUPdt=SCENT <br /> 537 EAST FULTON STREET <br /> sv=Torr, c,A 95,104 <br /> t�'ti9} 4�t:,-:r.'U1.iS 5J15J2�15 <br /> CUSTOMER NUMBER 6081745-018 GENERATOR'S REcuSTRAMON# <br /> 2A.DESCRIPTION OF WASTE 2S• CONTAINERTYPE 2C.NO.OF 21). VOLUME <br /> UN3291,Regulated Medical Waste,n o s., CONTAINERS <br /> 6 2,PGII- TBOS - 40 C-:al Tub (Bio) (s.3 M. ft) Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s, T84 9 _ 3-1 Gal Tut, (Bi(p) (4. cu ft)6.2,PGO T1349 Ft. <br /> p UN3291 <br /> 23PG1I Regulated Medical Waste,n.o,s., T$14 - 44 Gal Tut`(Bi0 (5,9 CIA ft) ?I <br /> Cu FL <br /> Q UN3291Regulated Medical Waste,mos., TB21-(BIG)dTP15-(Patl2)JTY15-(Cheino)tis Sal Tub(2.7= ) <br /> 6 2,PGII Cu FL <br /> t!I U143291'Regulated Medical Waste,n.o,s., <br /> tZ 6.2,PGII ki631-(Eit�)JVlP31— t1 <br /> (Pa �)/ C31-(Cl1n� <br /> �� 4}31 Gal Tu3�(4.14CU T) Cu FL <br /> UN3291, <br /> 2GIiRegulatedMetllcalWaste,nos, <br /> ,PW843-(Bio)/PW43-(Path)IC14T43-(Gliemo) tial Tub(5.7CUFT) <br /> Cu Ft. <br /> UN3291,Regulated Medical Waste,n o s, <br /> 6.2,PGII KRB - Biosystems cardboard Box (4.2 cu ft) Cu Ft <br /> UN3291,Regulated Medical Waste,n.o.s., ® i <br /> 62,PGII Pg<02- 2 Phe' ®.3 Cut. 1 O' S Cu Ft <br /> i Cu Ft <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately T®TALS ® 3 12- 1 Cu Ft. <br /> described above by the proper shipping name,and are classified;packaged,marked and labelled/placarded,and <br /> are in all respects In proper gqndition <br /> �for transport according to a 1lcable international and national governme air fations" UV <br /> PnntediTyped Name U <br /> �W®t� r Q Signature I Data J& - <br /> 4.TRANSPORTER i ADDRESS: Phone#: ($$ } }$ -11 7 Z2 <br /> Stt3riayOl e, T LIC. This is a Th e�ugh St 1M Ment ARRlicable Permit Numbers- <br /> s. _ 4L3& W. Swift Astr? Hauler Reg# 3400 <br /> N FCertno,CA 93722 <br /> Q d TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> cc <br /> +/ j 6 <br /> t- Print/Type Name RY2 ' G[/YaGL Signature Date ✓� I `S <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#: <br /> ION g a Applicable Permit Numbers: <br /> ao <br /> d <br /> i INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrfnUType Name Signature Date <br /> m 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> 5!R w Applicable Permit Numbers: <br /> 0 <br /> N a a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> ¢fix <br /> - Print type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Tran1birred containers, •-3 cu It to , North Salt Lake,UT <br /> y. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Slgnature Date <br /> ORIGINAL <br />