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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />&BE Of EMERGENCY CONTACT: CHEMTREC 1.800.42 STANDARD MANIFEST 001-10-06-STD4: 126 - 17 CUSTOMER NO.21 MDFROO LEKK
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDIM CE
<br />1617 N CALIFORNIA ST
<br />TO N, CA N204- 6117
<br />II IIIIII�IIIIIIIIIIIINA�M
<br />(209)451-9031
<br />CUSTOMER NUMBER 6114 A&7 -0m GENERATOWS REGISTRATION #
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labeliedtplacarded, and
<br />aggJc ll respects Tn proper condition for transport according to applicable International and natlo nmental c ions."
<br />nted/Typed Name wf�wI nature
<br />T SPORTER 1 ADDRESS:
<br />Stan inc. This is a Through Shipment
<br />4135 W. 611ift
<br />MD. Fmno,CA 93722
<br />¢a TRANSPORTER CERTIFICATION: Receipt of medical waste as desc
<br />~ Print/Type Name Signature
<br />S. INTERMEDIATE HANDL R / RANSPORTER 2 ADDRESS:
<br />a�
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrIntlType Name Signature
<br />ro 8. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />�a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />T. DISCREPANCY
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />Phone #{888)783-742
<br />Applicable Permit Numbers:
<br />Hauler Rog# 3400
<br />Date
<br />1-C
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />a
<br />2A. DESCRIPTION OF WASTE
<br />213. CONTAINER TYPE
<br />0 SC. Alternate Facility: U 8D. Alternate Facility:
<br />2PGIj Regulated Medical Waste, n.o,s.,TIM
<br />- 28 Gal Tub (Bio) (3.7 eu 1t)
<br />e, Inc. lncirlen>tor)
<br />6
<br />C!
<br />4136 W.
<br />i°IE o
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />8 - 37 Gal Tub (Rio) (4.9 cu t)6,2,
<br />1
<br />PGII
<br />M
<br />Regulated Medical Waste, n.o.s.,
<br />1 Gal Ugft) (5.9 eu R)
<br />er
<br />6U23229r�11,
<br />aUN3291,
<br />Regulated Medical Waste, n,o.s,,
<br />1 1 V
<br />6,2, PGII
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TREATMENT F rtify that
<br />2
<br />6.2, PGII
<br />h
<br />received the above IndicAldd wastes In
<br />GII Regulated Medical Waste, n.o.s.,
<br />W1343 43{-- WC434_) tial Tub(5.7CUFT)
<br />6.2.
<br />Regulated Medical Waste, n.o.s,,KR®
<br />2,
<br />- Bl ems Cardboard Ou (4.3 cu ft)
<br />6 PGIE
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labeliedtplacarded, and
<br />aggJc ll respects Tn proper condition for transport according to applicable International and natlo nmental c ions."
<br />nted/Typed Name wf�wI nature
<br />T SPORTER 1 ADDRESS:
<br />Stan inc. This is a Through Shipment
<br />4135 W. 611ift
<br />MD. Fmno,CA 93722
<br />¢a TRANSPORTER CERTIFICATION: Receipt of medical waste as desc
<br />~ Print/Type Name Signature
<br />S. INTERMEDIATE HANDL R / RANSPORTER 2 ADDRESS:
<br />a�
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrIntlType Name Signature
<br />ro 8. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />�a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />T. DISCREPANCY
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />Phone #{888)783-742
<br />Applicable Permit Numbers:
<br />Hauler Rog# 3400
<br />Date
<br />1-C
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />a
<br />. asignated Facility:
<br />® Ba. Alternate Facility:
<br />0 SC. Alternate Facility: U 8D. Alternate Facility:
<br />rl , Inc. (Autoclave)
<br />e, Inc. lncirlen>tor)
<br />Styli e, Inc. (Auboclave) Covent& Marion, Inc
<br />4950 lilnddldtia! Road NG
<br />C!
<br />4136 W.
<br />i°IE o
<br />N.
<br />NwM G" Lei*, UT 94054
<br />15151 Drift
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<br />21
<br />TREATMENT F rtify that
<br />f have been authorized by the applicable
<br />state agency to accept untreated medical wastes and that I have
<br />h
<br />received the above IndicAldd wastes In
<br />accordance with the requirement outlined
<br />in that authorization.
<br />Print/Type Name
<br />NEW At 11
<br />. , .,
<br />lu
<br />Date
<br />Cu Ft.
<br />r,
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