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_ MEDICAL,WASTETRACKING FORM NUMBER
<br /> ®i®® te�'I(ycle j WE �EJIEYENCY ONTACT:CHEMTREC 1.800.424.93 STANDARD MANIFEST 001-10-06-STD
<br /> •7 �` CUSTOMER NO.21132 MD ROO 62DV
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN:Gus Ropelidis i
<br /> LA SALEM CONVALESCENT
<br /> 537 EAST FULTON STREET
<br /> STOCKTCtN,Cil/ 5204
<br /> , (209)488-2006 9/24/2018
<br /> CUSTOMER NUMBER d "�"u� GENERATOR'S 1`19OWTHATION N
<br /> 2A.DESCRIPTION OF WASTE 20. CONTAINERTYPE 20. NO.OF 2D, VOLUME,
<br /> CONTAINERS
<br /> 6 2,PGII Regulated Medical Waste,n.4s., 80 _2$rail ( )(3.7 ) Cu Ft.
<br /> 6UN32911 Regulated Medical Waste,n,o.s„ TB49.37 Gal Tub(ft)l(4.2 ) Cu Ft,
<br /> CC UN3291 Regulated Medical Waste,n.4.s,, TB14–44 Gal Tub(Bb)(5.9 ) Cu Ft.
<br /> ® 6,2,Pal
<br /> UN3291 Regulated Medical Waste,nZ—$.' q u
<br /> 6.2,PGII Cu Ft.
<br /> W32911� Cu Ft,
<br /> Regulated Medical Waste,n,o.s„
<br /> W 6,2,
<br /> 6,23Pal Regulated Medical Waste,n,os., M34_JA P43 Gal Tab(5,701JIM Cu Ft,
<br /> 6 N32Regulated
<br /> Regulated Medical blasts,n,q,s., KR®,-Siosys rms Card (4.3.cu 9)
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.o,s,,
<br /> 6.2, Cu Ft.
<br /> PGi�
<br /> UN3291 Regulated Medical Waste,n,4s„ C
<br /> 6,2,PGi)
<br /> 3.Generator's Certification:°1 hereby declare that the contents of this consignment are fully and accurately TOTALS ` Cu Ft.
<br /> described above by the proper ahlppIng name,and are classified,packaged,marked and labelled/placarded,and —•
<br /> are in all respects In proper condition f tr ns rt according o applica international and national gover at fegulatio s"
<br /> I
<br /> gq
<br /> X ;Pdnte pad Name SI nature Data
<br /> ¢ 4.TRANSPORTERIAD RES Phone x(806)783-74 2
<br /> 413 IA1►e El This is Through Shipme Applicable Permit Numbers;
<br /> a Fresno,Qk 93722 Hauler RegN�344E
<br /> a TRANSPORTER CIERTIFICATION:ReceIp of meds 11 waste as described a
<br /> Print/Type Namej.rlq_��,Signature DataI.- /z
<br /> 5,INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone tt:
<br /> N Applicable hermit Numbers;
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above. i
<br /> PrinVrype Name Signature Date
<br /> ro 6.INTERMEDIATE HANDLER 3/`TRANSPORTER 3 ADDRESS: Phone f1:
<br /> I
<br /> 1h Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above,
<br /> i PrInV'Type Name Signature Date
<br /> 7,DISCREPA Y INDICATION
<br /> Designated Facif : reB,Aftemata Facility: aC.ANamate Facility; Iso.Attemats Facility:
<br /> Sterlwcb, Inc,Aub Inc, Ind a Start Inc,Aut Ow anta Marion, Inc Incinerate
<br /> 4135 W.Swift Aire oro Drive 1551 Shelton Drive 4850 Brookleke Road NE
<br /> Fresno.CA 93722 take.UT 840 ouster CA 95023 Brooks OR 97305
<br /> (888)783-7422 171 ( 8)78 -7422 (505464890
<br /> TS/OST22 D ,!NKNEOF#1'tx -38 OST-83 Perrrtlt#384
<br /> TREATMENT F L4��''11����1 r�'yy that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> I- § received the irtdI t k sten In accordance with the requirement outlined In that authorization.
<br /> Print/fypa Name Signature Date
<br /> Tralfisfirred_ t t#ta Wren, ou It to :Bra .
<br /> Transferred containers, CU R to : N.Sall Lake, UT
<br /> ORIGINAL
<br />
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