0_2001-2019 - Laserfiche WebLink

Home Browse Search

MEDICAL WASTE TRACKING FORM NUMBER OsQ Sterweycte° 11yFEFcICYCOa111CT:CHElYCiREC1-a00.424-8300 STANr�nRo�uwIFe8Tm1•!ao&srD '•® rea.pr.aea,sre,x CUSTOMER NO 21132 MC)EROOHItiDN 1. Generator's NameA*W?ss and Telephone Number SILL 1CDI�"KCAL CE 1617 N CALUORNCA ST STOGxmx, CA 96204- 6117 (209) 451-9031 3/29/2016 CUSTOMER NUMBER 611.852-001 GEN6RATDR'S REGISTRATION # 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO. OF 21). VOLUME UN3291 Regulated Medical Waste, n.o.s., TBDS — 40 tial Tub (Bio) (5.3 cu ft) CONTAINERS 62. PGII Cu Ft UN3291, Regulated Medical Waste, nos., .Gu Ft 6.2, PGII CC ® UNS291PolRegulated Medical Waste, nos„ — a CU Ft `Z6 2 p91 Regulated Medical Waste, nos„ Cu Ft - QC W UN3291 Regulated Medical Waste, n.o.s., — 011 wubje.111CUM) — 1Z 6.2, PGII Ft UN3291 Regulated Medical Waste, n o.s., — Bso — e cs:t — c emo as T cUrT 6.2, FGII Cu Ft UN3291 .ystmcardboard Box cuft) 6.2, Pali , ., _ Cu Ft. UN3291 Regulated Medical Waste, n.o s' 1 Cu Ft 6 2, PGIi UN3291 Regulated Medical Waste, n.o s., Ft 6.2, PGIi S. Generator's CartiNcation: •I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu FL described above by the proper shippfng name, and are class fled, packaged, marked and labelled/placarded, and ar all respects In proper condition for transport according to applicable international and nate e ulabons" Intedffyped Narnek\l\ ° cc NSPORTER 1 AWjWjcy0je, Inc. ® This is—a Thr h h:i pm t Phone #: 4135 W. Swift Ave AppI lu W" er e'gl'3400 a Fresno,CA 93722ME � n. TRANSPORTER CERTIFICATION: Receipt of medical waste as descR a Pdrib lype Name, Signature Date 6. INTERMEDIATE FiA LE 2 11RANSPORTER 2 ADDRESS: Phone 6• Applicable Permit Numbers: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. PdnVlype Name Signature Date e'o 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS Phone i1: g Applicable Permit Numbers, 11L INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. in PrinUlype Name Signature Date i 7. DISCREPANCY INDICATION t:atod Rscllity: ae. Alternate Facility: SC. Alternate Facility: ® So. Akemate FacUrty: Stbricycle, Inc. toStaticycle, Inc. Stericycle, Inc. -I 4136 W, OMAV* 90 N. F®Xb01'o Dr1V* 1651 Shelton Drive Frasno.CA 937 - North Salt Lake, UT 84064 Hollister. CA 95023 Z (866)783-7422 S/o T22a22 A� 2g ®16 (066)783-7422 os�T 83 �z M TREATMENT FACILITY: d cert that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have i F received the above indicated wastes In accordance with the requirement outlined to that authorization. Pr Wfte Name SI a r Date a i � I M