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•:;:! tericycle! <br />ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424* <br />to 4S 126 — 15 CUSTOMER NO. <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10 -08 -STD <br />u ' 1 i _ 5 <br />TrMrdVm—"—M% r :6""'OR <br />1. Generator's Name, Address and Telephone Number II <br />ATTN; 111111111 moll in I <br />aM.L <br />1617 N CALFORNAST <br />STOUTON, CA 6117 <br />(M) 451 -Mi <br />11 1s <br />GENERATOR'S REGISTRATION k <br />CUSTOMER NUMBER 2M <br />2A. DESCRIPTION OF WASTE <br />20. CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />6 2PGIj Regulated Medical Waste n.o.s., <br />3 <br />OtN Tub S.7 it <br />CONTAINERS <br />CII <br />Cu Ft. <br />6 23PGIj Regulated Medical Waste, n,o.s., <br />6 _ 37 Iasi 74 ON) (4.9 Sar iI) <br />Cu Ft, <br />M <br />® <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />1 44 GIM ) (5.1I CY it) <br />c Cu Ft. <br />Q <br />UN3291i Regulated Medical Waste, n.o.s., <br />- 1 1 1 2Q tial T 2.7WM <br />cc <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n,o,s„ <br />W <br />62, PGII <br />Cu Ft. <br />623 91 Regulated Medical Waste, n.o.s„ <br />PG I4 <br />bA <br />Gal <br />1VIX5.7cum <br />Cu Ft. <br />6 23PGIj Regulated Medical Waste, n.o.s,, <br />KR aWsydom Cwtilboard On 4,3 <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 F. <br />3. rator's CortlficaUon:.I hereby declare that the contents of this consignment are fully and accurately T®TAL$ ® <br />` Cu Ft. <br />ri above by the proper shipping name, and are classified, packaged, marked and labelled/piacarded, and <br />e I at respects in proper Condition for transport accorcling to applicable international and Haff regulations" <br />krnmental <br />int ped Name a Si to <br />Dat <br />NSPORTER 1 ADDRESS: <br />OThis Is ShOraM <br />Phone N( ) -7422 <br />1111C. i Thmuoh <br />4135 <br />Applicable Permit Numbers: <br />H=W R <br />FrmwCA 63722 <br />EL <br />TRANSPO E F N: Receipt of medical waste as descri <br />Print/Type Name Signatura <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone If: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />�, <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone M <br />9i <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUType Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Daslpr►aW Facility: 8B. Artamate Facility: ❑ 8C. Albrnab Facility: <br />E18D. Akamate Facility: <br />) AM StN. M1a. If111 ori ) A <br />e <br />WKS351 Iton <br />4135 AW 90if <br />4 R <br />Firwam. NE aliflz CA 23 <br />t74 UT 64W4 <br />eto 0730 <br />sot t ( 73 7422 <br />ST <br />13f�s 1111 <br />-22 3A448/J" ST <br />P k <br />3 <br />NOV o 201 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the abovQQ*A*wastes In accordance with the requirement outlined In that authorization. <br />Print/Type Name Signature <br />Dale <br />TrMrdVm—"—M% r :6""'OR <br />