|
MEDICAL WASTE TRACKING FORM NUMBER
<br />tericydex STANDARD MANIFEST 001-10.06-STDfWE t
<br />CUSTOMER NO.2 MDFROO LHAW
<br />1. Generator's Name, Address and Telephone Number limit
<br />ATTN:
<br />1111111111 IN 1111111111111
<br />GSL
<br />1817 N CALIFORNIA ST
<br />STOCKTON, CA - 6117
<br />(209)451-9031 1/11/2019
<br />CUSTOMER NUMBER 6111852 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />2C. NO, OF
<br />20. VOLUME
<br />,Regulated Medical Waste, n,o.s,.
<br />TW _ 28 Gill Tub ( ? t 3.7 eu 0 )
<br />CONTAINERS
<br />6.2, PGII
<br />6.2. PG
<br />Cu Ft.
<br />Regulated Medical Waste, n.o.s.,
<br />9 _ 37 Gal Tulb ( ) (4.9 CU R)
<br />6N322991
<br />Cu Ft.
<br />UUN329911� Regulated Medical Waste, n.o.s.,
<br />_, Gal T ) (+� 9 to E)
<br />O
<br />6.2, PGCu
<br />Ft.
<br />QUN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />,
<br />cc
<br />PGII
<br />Cu Fi.
<br />Cu
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Et—
<br />t
<br />WZ
<br />UN3291
<br />s 2, PGIj Regulated Medical Waste, mos.,
<br />34 43 C43„(__) Gal Ttb(5.7CLFD
<br />Cu Ft.
<br />6 2, PGII Regulated Medical Waste, n.o,s.,
<br />KR�__ em Qvillboard On (4.3 oU rt)
<br />/
<br />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 TOTALS 00- 1 1 Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />"I respects in proper condition for transport according to applicable international and nationerUqyernmentall regulations"
<br />)I
<br />/
<br />P nted/Typed Name I natur to L.
<br />ccTRA
<br />PORTER 1 ADDRES : Phone N , - 4
<br />� � This 19 Shipment
<br />®
<br />Applicable Permit Numbers:
<br />4135
<br />I R Ft*
<br />,CA 93722 Hauler Re 3400
<br />Q Z
<br />TRANSPORTER CERnFICATI N: Receipt of medical waste as desAa�
<br />j L
<br />Print/Type Name?Zs Signature Date
<br />`a
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone.1h f!;
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnVTW m Name Signature Data
<br />7. DISCREPANCY INDICATION
<br />BA. 0ssignaW Facittly: 68. Atbmab Facility: cc. Alternate Facility: SD. Altamata Facility:
<br />Inc. ) Sterkycle. Irtc. (tnchtsrr) e, Inc. (Autoctsve) Covento Marion, Inc
<br />N. f Drh»�1551
<br />S
<br />4186 W. SYMllt Awl Shelton 400 BrookleM Road NE
<br />W
<br />Fresno, CAS ANNE ORTq North Salt Lake, LIT 84054 Holiitltter, CA 95023 Brooks, OR 97305
<br />( )7837422 (801)936.1171 (866)783-7422 (6055139308910
<br />-22 811k36 ST 83 Pere t 364
<br />,AN 2019
<br />TREATMENT FAC citify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I.have
<br />ti
<br />received the above ndicated,Gvastes in accordance with the requirement outlined in that authorization.
<br />PdnVType Name Signature Date
<br />cu I to, Smah, OR
<br />Trarillithrired amiabom, cu A to : N. Sak Lake, UT
<br />
|