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MEDICAL WASTE TRACK.ING FORM NUMBER
<br /> Stericycle" IN CASE OF EMERGENCY CONTACT:CH MT E 1-800-4_ 300 STANDARD• MANIFEST 001-10-06-STD
<br /> '1110,00,411, 0 E ' R'C -B 2 9 D
<br /> Pmtecting People.Reducing RIA: j
<br /> _ttl� -#-. '?)J. 12 CUSTOMER NO.21132
<br /> 1.Generator's Name,Address and Telephone Number Ali I I
<br /> AN JCiA(,'-'.1J`fN I
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<br /> GENERATORS REGISTRATION#
<br /> CUSTOMER NUMBER
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., °..`;;;r1°..`;;;r1 "g;:uta (12 r_'u ft) CONTAINERS
<br /> 7,
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<br /> UN3291 Regulated Medical Waste,n.o.s., :3 7 rza 1 Tub (13'ia) 09 �-
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<br /> CC UN3291,Regulated Medical Waste,n.o.s., TTJ14 14 G'.11 TIA210die,) (5,9 ft' )
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<br /> UN3291,Regulated Medical Waste,n.o.s., TV2 1 20 Cal. 2 -7
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<br /> W UN3291,Regulated Medical Waste,ri,o,s, TDJ 5 20 Ga1 Tub (Pat.1--) 12.7 Cat ft,
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<br /> UN3291 Regulated Medical Waste,n.o.s., i 5 2 ri Q e I Tub 2�7 cur ft)
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<br /> UN3291,Regulated Medical Waste,n.o.s.,
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<br /> UN3291,Regulated Medical Waste,n.o.s.,
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<br /> 3*Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 101. 2- 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 copcUtion for transport according to applicable international and national governmental regulations,"
<br /> x Printedfryped Name —Signature Date
<br /> _=_LL4 4
<br /> 4.TRANSPORTER 1 ADDRESS: Phone#:
<br /> F1 :riiis, zi Therjugh Shipmrialt
<br /> UuI Applicable Permit Numbers:
<br /> 4135 1 ...' A
<br /> 0 9.372*z
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<br /> CL Z TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Print/Type Name Signature .4 Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> W Applicable Permit Numbers:
<br /> age
<br /> Receipt me
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<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Ript of medical waste as described above.
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<br /> PrintrType Name Signature Date
<br /> w 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
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<br /> 0.�zl INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
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<br /> Print(Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION tt to - North Salt Lake,UT
<br /> 99P8A.Designated Facility: E]8B.Alternate Facility: E]8C.Alternate Facility: r-1 8D.Alternate Facility:
<br /> str Steelcydp,�nc-Autodavri 3+9ri-,ide Inc-Autoclave
<br /> rfc.�de tnc-Autodava- Stericyde inn-Incineration 2775 8 26TH STREEr
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<br /> SON Ci ill I 1001 V*_ 1,345 Doolftle 061A,-Ste C
<br /> 31,' F"FAVE
<br /> 0722 wf)PTH SM LAXE CITY,UT San Laandrrr,CA 24577 V_--PNON,CA 93023
<br /> L<L 1 02311.1132 3000
<br /> f6159)2 75- I i 21 (610)6
<br /> I... � 936- 1 62, 2177
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<br /> aTREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Printrrype Name Signature Date
<br /> 1 FAVF AT rFR11FR A
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