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MEDICAL WASTE TRACKING FORM NUMBER <br />!® a!teriCyc V SE OF EMERGENCY CONTACT: CHEMTREC 1400-424- STANDARD MANIFEST 001-10.06-9TD <br />•7 • 0 i 123 - 22 CUSTOMER NO, 2 RDFROO L6BE <br />1. Generator's Name, Address and Telephone Number <br />TT: <br />OLL <br />1817 N CALFORNIAST <br />SMCKTON, $117 <br />CUSTOMER NUMBER 611 1GENERATOR's REaismxnON 0 <br />2A. DESCRiPTiON OF WASTE J213. CONTAINERTYPE <br />UN3291, Regulated Medical Waste, n,o.s, <br />6.2, PGII I - 28 Gal TUb (NO) (3.7 Cil R) <br />UUN3229911j Regulated Medical Waste, n.o.s., - 37 Oil (4 .9 OY �) <br />CC UN3291, Regulated Medical Waste, n.o.s. 14 " Qat ) (5.9 OY 11) <br />p 6.2, PGII <br />a UN3291, Regulated Medical Waste, n.o.s., , 1 j <br />jZ 6.2, PGII <br />W UN3291, Regulated Medical Waste, n.o.s., <br />tZ 6.2, PGII <br />6N3291 Regulated Medical Waste, n.o,s,, Gal Tilb(5.7 <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII KRB - MOSY1111111111111111111111111 Cwdbowd Ba(4.3 Oil 2) <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 CertJflcation: "i hereby declare that the contents of this consignment are fully and <br />deverl >9 above by the proper shipping name, and are classified, packaged, marked and labelled <br />&F-5-11 spells In proper condition for transport accoordiing� to applicable international and nati <br />3 Pri yped Nam %'rl 1 Sian <br />4, TR ORTER 1 ADDRESS: <br />4435 <br />FnamAk 11113722 <br />a TRANSPO RTijIC N: Receipt of medical waste as <br />TOTALS ► <br />and <br />ental regulation8'� <br />° PrinVType Name Signature <br />5. INTERMEDIATE HANDL 2 /TF{ANSPORTER 2 ADDRESS: <br />a� <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />I PdntUType Name Signature <br />E <br />C. NO. OF <br />CONTAINERS <br />u <br />Mm <br />VOLUME <br />Cu Ft. <br />Cu Ft. <br />Cu Ft. <br />Cu Ft. <br />Cu Ff. <br />Qu F <br />Cu Ft. <br />Date <br />Phone 4049W427 <br />Applicable Permit Numbers: <br />Hader R"111 U80 <br />Date I/J::2w <br />Phone N: <br />Applicable Permit Numbers: <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone C <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdnt/Type Name Signature Date <br />T7. DISCREPANCY INDICATION <br />8B. Alternate Facility: <br />1* 94 Ldo. UT <br />] 8C. Albmwte Facility: <br />1%, . Oda <br />iswieun <br />u 81). Akemab Facility: <br />. in kwkwrim <br />00 BrooMix RoW HE <br />Brodm OR 9730 <br />59— <br />Pen"k 111364 <br />TREATMENT LIEF I ikii.that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined In that authorization. <br />PrintfType Name Signature Date <br />