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MEDICAL WASTE TRACKING FORM NUMBER <br />-%-,e StericycIe` LASE OF EMERGENCY CONTACT: CHEMTREC 1800 42 S7ANDArip MANIFEST 001 -10 -06 -STD <br />J M -46—r. 7�a se CUSTOMER IN 2 ......_„„- <br />1. Generator's Name, Address and Teleohone Number <br />Trumbirmlif ' so I a <br />ORIC41NAL <br />AWN: I <br />GILL MDICAL CEWM[ F l <br />1617 x CALIFCRIIA ST <br />STIOCKTION, GA 95204- 6117 <br />0111141111 A— <br />CUSTOMER NUMBER _ GENERATOR'S REGISTRATION M <br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 20. VOLUME <br />UCONTAINERS <br />N3291, Regulated Medical Wade, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.c.s., <br />6.2, PGII <br />Cu Ft. <br />Q <br />UN3291, Regulated Medical Waste, n.o.s., <br />® <br />6.2, PGII <br />Cu Ft. <br />IX <br />6 23PGII Regulated Medical Waste, n,a.s., <br />821- ( } %?1P15— ( )/?Xi5— ( ) 20 gal Tt1b (2.70tttr?) <br />Cu Ft. <br />W <br />UN329i, Regulated Medical Waste, n.o.s., <br />WWI <br />6.2, PGI <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />5.2, PGII <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 />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Et <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TIAL$ ® , <br />Ca Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />respects in proper condition for transport according to applicable international and naT rnmental regulations” <br />s <br />W�Wted/Typed NameftrSignature <br />TRANSPORTER 1 ADDR : Phor B3-7422 <br />w <br />y. <br />steeicy�ale, Inc. This is a Through shipsont Applies be rmitNumbers: <br />C o <br />rc <br />4135 9, wilt Ave eauler 3404 <br />V) <br />Freano,CA 93722 <br />a ¢ <br />TRANSPORTER CE FIC T1ON: Receipt of medical waste as descri abo <br />~1 <br />Print/Type Nam Signature Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone N: <br />cc <br />RZ <br />Applicable Permit Numbers: <br />g <br />it- <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />k: <br />B. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phonetr <br />ma W <br />Applicable Permit Numbers: <br />H 2? <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />� W = <br />Printrrype Name Signature Date <br />7. DISCREPANCY INDICATION <br />ka <br />8A. Designated Facility: B.ate Facility: 8C. Altemate Facility: 8D. Alternate Facility: <br />..t <br />416 ilrf, ' Y►c. Mnt». Y�c. kIC <br />1661 M Dom 4M BM*Mdal fted NE <br />G <br />G 1111=11 ElMoke, OR IMZ <br />lag <br />m (M)783-7422 <br />� <br />X <br />\ <br />TREATMENT Il\�tCILITY,4 e*Vi&ify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F- <br />received the above hated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name Signature Date <br />Trumbirmlif ' so I a <br />ORIC41NAL <br />