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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ®® dQ STANDARD MANIFEST 001-10-06-STD
<br /> ® IER W i TT4.1€'IPal(.271H
<br /> 1. Generator's Name,Address and Telep
<br /> AT TN'Rabneet KL.
<br /> 3'.g:.t.l Ay Ak G I l Hyl� A . f e l T
<br /> WEET
<br /> (20�473--7472 2/17/2020
<br /> CUSTOMER NUMBER 6156779-001
<br /> GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> 6.2,PGII Regulated Medical Waste,n.o.s., 117804 a 2.8 (* l Tub (Bio) "( .�
<br /> CONTAINERS
<br /> cu ft� Cu Ft
<br /> UN3291,Regulated Medical Waste,n.o.s., 1'•8,49- 37 Gal Tub O')
<br /> 6.2,PGII Cu Ft
<br /> p 6.2,PGII Regulated Medical Waste,n.o.s., 1,'� `1 w Gab T IRE( ill) CU ) j t
<br /> � Cu Ft
<br /> QUN3291 Regulated Medical Waste,n.o.s., ' „- 1a � Yk� s� gyp ., *
<br /> fY 6.2,PGII Cu Ft
<br /> W UN3291,Regulated Medical Waste,n.o.s.,
<br /> ILLI 6.2,PGII Cu Ft
<br /> 6.2,PGII Regulated Medical Waste,n.o.s., VJ,,. iW •°(—_.—) 43-j Gal Tub'57CUFT)
<br /> Cu Ft
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII -13josystemis CardboardBox(4.3 mi ) Cu Ft
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
<br /> Cu Ft
<br /> UN3291,Regulated Medical Waste,n.o.s.,
<br /> 6.2,PGII
<br /> Cu Ft
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately, TbTALS ® Cu Ft
<br /> described,above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> aspects in proper condition for transport according to applicable international and national goverprpental cgulatlo�ls°
<br /> are in all ff
<br /> i
<br /> )arinted/Typed Name "'Signature ate
<br /> l ” 'D
<br /> 4.TRANSPORTER 1 ADDRESS: r' Phone#: $ Y
<br /> 1'ztericyrk-, Inc. EI ThiSiiii.Through Shiplylefilf Applicable Permit Numbers:
<br /> s N Fresno,(. :937211-
<br /> L Z< TRANSPORTER-CERTIFICATION: Receipt of medical waste as described abgve
<br /> Print/Type Name ! 1 ✓ Signature Date F
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: _ Phone#:
<br /> i ui
<br /> j a¢ Applicable Permit Numbers:
<br /> :®W
<br /> iLUZ
<br /> iw= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Z
<br /> Print/Type Name Signature Date
<br /> W 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> w Applicable Permit Numbers:
<br /> X a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> LU
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> P8A.Designated Facility 8B.Alternate Facility: 8C Alternate Facility. ❑ 8D.Alternate Facility:
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<br /> r;j..Fiixl�elr*Driko 51,5 � i r t �' '�, a.$ ��E
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<br /> r,, Rn ;:4 93722 PIwt'Sk UT U0&3
<br /> w/cxa lV-2 td? „ISIt ;ra f£ T sa'
<br /> c REATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> ceived the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
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