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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle' "SE OF EMERGENCY CONTACT:CHEMTREC 1-800-21ft STANDARD MANIFEST 001-10.DB-STD
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<br /> 1 Generator's Name,Address and Telephone Number
<br /> ATTN:
<br /> 400 'S AVE,
<br /> SIVU1011, CA 95"-,03
<br /> (2kW 90-513l,'i
<br /> CusromEn NumSFR Gr=NEFIAMR-s REGismnoN 0
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 20. VOLUME
<br /> REGULATED MEDICAL WASTE,nx s..6.2, CONTAINERS
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<br /> 3.Generator's Certification.'I hereby declare that the contents of this consignment are fully and accurately TOTALS 00- 0 Cu Fl.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and overr
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<br /> are in all respects in proper condition for transport according to applicable international and nat-ionanationaltest�enTat I
<br /> x7 Prfiried(Typed Name rTt PSignature Date
<br /> 4.TRANSPORTER 1 ADDRESS: Phone 5 b 9 7 0
<br /> UJI xnc— Applicable Permit Numbers:
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<br /> IL q TRANSPORTER CERTIFICATION:Recetilpt at medical waste as described above.
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<br /> Prinlf`fype Name Signature
<br /> Date
<br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone if:
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<br /> cc Applicable Permit Numbers,
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<br /> I INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION- Recejptoi medical waste as described above.
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<br /> I Prinl/Type Name Signature Date
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<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
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<br /> Prinlff-ype Name Signature Date
<br /> 7.DISCREPANCY INDICATION
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<br /> 8A,Designated Facility. E]013,Alternelo Facility- 0-8C.Alternate Facility: 8D.Alternate Facility:
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<br /> INC 5f PR I CY CLE I.NC STEPiCYCL.E.INC STERICYCLE INC
<br /> '.4, 20 N QR'1q4 I I fUll VVEST 9a-331 ORRISAV!z '11775 E 26TH S'MF-E"T
<br /> U; -19FRESNO,CA 93?22 NICP"W.'iALTLAXE CIT�,LI"I 51LINI "Y,(,*A 91�;2
<br /> VERNON'.CA Q0673
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<br /> a TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- ii received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> PrInt(Type Name Signature Date
<br /> LEAVE AT GENERATOR
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