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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 111Mle Stericycle' SE OF EMERGENCY CONTACT:CHEMTREC 1-000-2 STANDARD MANIFEST 001-10-06-STDF ft
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<br /> 1. Generator's Name,Address and Telephone Number
<br /> T 411 MARANOiIiIi
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<br /> 400 S AVE
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<br /> Custromza NUMBER GENERATOws.RzatmmiaN it
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 2D. VOLUME
<br /> REGULATED MEDICAL WASTE,ri.a.sj.2,I CONTAINERS
<br /> UN 3291,PG 11 - 4740 1'4,11 1111h Iviin" 117 .-11 t-1 I Cu Ft.
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<br /> LIN 3291,PG 11 T UZI 9 - 3! fa I Rxo) {Q.1; cu E T.I Cu Ft.
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<br /> UN 3291,PG 11 TFt14 - 4-1 Gal Tub B.-Lo I Cu ift) Cu Fl.
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<br /> X LIN 3291.PG 11T1322 - Cu Fl.
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<br /> LIN 3291,PG 11 -;t-1 Cu Fl.
<br /> REGULATED MEDICAL WASTE,
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<br /> REGULATED MEDICAL WASTE,nm.s.,5.2,
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<br /> 3.Generator's Certification:'I hereby declare that the ronlem"of this consignment are fully and accurately TOTALS 00. Cu Ft
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and_
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<br /> are in all respects in proper condition for transport according(6-applicabre International and national governti-inia
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<br /> APriniedrryped Name
<br /> L/I SignafCre Date
<br /> cc 4.TRANSPORTER 1 ADDRESS: Phone 9: -j I I
<br /> 1JU Applicable Permit rf:
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<br /> CIL Z TRANSPORTER Receipt of medical waste as described above.
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<br /> Prini Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone N:
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<br /> W Applicable Permit Numbers:
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<br /> INTERMEDIATE HANDLER]TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinVT-ype Name Signature Date
<br /> tu S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone H:
<br /> WIQ CC Applicable Permit Numbers:
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<br /> Q 2 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br /> a:- PrintlType Name Signature Date
<br /> 7,DISCREPANCY INDICATION
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<br /> 8A.Designated Facility
<br /> U 11B.Alldim—aTie Facility: [:]-ft Altontatolllrac7i ij;--'—C[11WRI—tomate Fac—ifity-
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<br /> STEPICYCLE llqC STERICYCLO!ISI C- _11EPIC)ICLE"-INC STERiCYCLE INC
<br /> 11135",IV.30AFT AVE2,776 E 213-TH 5FREET
<br /> 90NOP'll-I I J0lJ'A4;-:ST 15 4 14,'.'�R R I'S AVE.
<br /> r-PEGI,110,CA 93 122 1110PTH sALI'LAKE c:I,N,.u r 7,3IJ l'! V AI-11:Y,CA 911�52 VEPNCN.CA 9002'-A
<br /> (559)27!x-09IR-4 ;:a)1)936- I L 55 ia!81 5Q11 -61137 (323)362-313 30
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<br /> uJx TREATMENT FACILITY: I certify that I have been authorized by the applicable slate agency to accept untreated medical wastes and that I have
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<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> [Priint/Type Name Signature Date
<br /> LEAVE AT GENERATOR
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