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ON <br /> • Ster( cle' MEDICAL WASTE TRACKIAG FORM NUMBER <br /> a,o rm«aatya�M+.arraMan>: IN CASE OF EMERGENCY CONTACT:CHEMTRE01-000.424.9300 STANDARD MANIFEST Om-lo WSTo <br /> _ CUSTOMER NO.21132 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Richard Rslcota [II I[I(I[(1[[ II[[1[f([I[III[[I[[![11[l1111f[[1![I <br /> maws 7(EN HOPE <br /> 2586 BUTBIT&WH AVE <br /> TRACY, CA 95376— 2165 <br /> 4 <br /> CusTOMERNUaBea o.o GaNERATon'6 FurmsmAnoud <br /> 2A.DESCRIPTION OFWASTE 28. CONTAINERTYPE I2c-..NO.OP 2D. VOLUME <br /> U03229 i1 Regulated Medical Waste,ass., CONTAINERS <br /> 11.2,PGUN3291 RO0ubi0d Medlee Waste,n.o.s„ Cu Ft <br /> 62,Poll _ <br /> O: 832P801�ROpulalOd M001wi V/asl0,n os„ - <br /> Cu FL <br /> Ff <br /> G UN3291 Enabled MedMai West,,,a a.&, <br /> r f Cu FL <br /> 2 &2•FGII TB21- 20 Gal Tub(Bio) (2.7 cu ft) <br /> W UN3291 Regulated Mi elcal waste,aO.S., r <br /> 8.2,PCIS _ � <br /> al <br /> UN3291 Regulated medical Waste, os <br /> n „ Vitt, 1prithl FL <br /> 62,P31) <br /> B 4,W1 ROOulaldd MOdiwi V/1310,:".0 a„ Cu FL <br /> &2 PGtl Regulated M.t0lcal Wade,n 0.S., - CU F <br /> Cu Ft <br /> 3.Genoretar's certification- hereby declare that the contents of this consignment are fully and accurately TOTALS' <br /> desenbad above by the proper shipping name,and aro dassthad,packaged,marked and Wtsopodlplaca and Cu FL <br /> are In a6 respells In proper Oondlllllo{n�b.{rp-Iymnspa l accorrdYYmT�g to applicable international and national gave must regule6orW <br /> Pdnied/ryped Name_.. +^v,1 tin <br /> Dnta� •Z <br /> 4.TSignature flANSPORTEfl 1 ADDRESS: Picone a: (r <br /> ❑ g p APphcebta Per �r�q1,�7 -1121 <br /> •0 4135 V. Swift <br /> IatC. TtriS i9 a Thtou h Shi trent AID'NamBOrh. <br /> 8135 A. Swift:Ave <br /> E N 8cesno CA 93722 sauler Reg# 3400 <br /> a TRANSPORTER ERVFICA'FION:Roc4kofmodicalwaste asdasenli o. <br /> P(binpo Name 14.1_11,! SlgnaW. Date <br /> S.INTERMEDIATE NANOLER 2/TRANSPORTER2 ADDRESS-. Phone d: <br /> Applicable Permit Numbers: <br /> fall INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recagrtof modical waste an described show, <br /> PnnViypo Name Signature Data <br /> �L 0.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone d: <br /> Q i Applicable Permat Numbers: <br /> _g l INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recolptof medical waste as described above. <br /> Pdntrrypo Name Signature Data <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers, cu A to:North Sari lake,UT <br /> } � A,Designated Fac0ltyi OB.Altimrlo FaalOty: [3 SC.Akomato Feaster: L]Go,Alliterate Facility: <br /> <4 St@rlcyolB,)tIC. S�rlCyCle,lrlkL StaifCyCl@,lnC. Stertcytl@,InC. <br /> a 4136 W,SW ItAYe 30 North Foxboro Or 1551 Shelton Od" 2775 E.26th St <br /> �1 Fresno,GA 83722 North Salt Lake,UT 84054 Hollister,CA 85023 <br /> Vernon,CA 90056 <br /> w (8DI)MS-1555 (831)830•)048 (323)362-3000 <br /> r M ngTggt�I EgAVV{E� 3A•448JA36 TS/OST83 TS/OST26 <br /> TREAYA66 PAN&r?ri)berlity thal I have been authorized by the applicable state agency to accept untreated medlcaI wastes and that I have <br /> I- received--the <br /> ��((above indicated wastes n accordance with the requlrament outlfnad In that aulhorizagon. <br /> PrinVpype ldaYntr 2013 <br /> 5lgnDlura Date <br /> I. . <br /> ORIGINAL <br />