|
MEDICAL WASTE TRACKING FORM NUMBER
<br />�;: @ ter'icycle'turte
<br />ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-42 STANDARD MANIFEST 001 -10.06 -STD
<br />0: 123 — 14 CUSTOMER NO, 21132 M]]FROOKIOV
<br />1'fansferred containers, ou ti to
<br />1. Generator's Name, Address and Telephone Number
<br />ATTIf ff i
<br />M
<br />GILL MEDICAL M14TE1Z
<br />1617 v CAurCER IA ST
<br />STOCtC -N, CA 95204- 6117
<br />(209) 451-9031
<br />511/20113
<br />l
<br />'y y
<br />CuMmesNumsER 6111852--001 GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2s, CONTAINER TYPE
<br />2C. No. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />PGI
<br />TBQ4 — 28 13ai Tub {bio} {3.7 cu it}
<br />CONTAINERS
<br />6.2,
<br />Cu Ft.
<br />-
<br />UN3201 Regulated Medical Waste, n.o.s„
<br />6.21 Poll
<br />TB49 — 37 Gal Tub (Bio} (4.9 cu ft}
<br />Cu Ft
<br />6 2a2I, Regulated Modica) Waste, n.o,s,
<br />TBl4 44 Gal Tub (Bio) (S. 9 cu ft)
<br />Pull
<br />Cu Ft.
<br />UN32g1, Regulated Medical Waste, n.o,s„
<br />TB21-» f } /TP15- ( ) jTY1S- f ) 20 Gal Tub f 2.7CUKT)
<br />,cc
<br />6,2, PGII
<br />Cu Ft
<br />UJ
<br />UN3291 Regulated Medical Waste, mo,s„
<br />6,2, P1311
<br />.Z
<br />Cu Ft.
<br />fi 23PSIj 01 Regulated Medical Waste, n.o,s„
<br />wB4.1— () /wt?43— () /i a43— { } tial Tub (S . 7CUFT)
<br />Cu Ft.
<br />UN3291 Regulated Modlcal Waste, n.o.s.,
<br />6,2, PGI)
<br />KR — Biosystems Cardboard Box (4.3 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6.2, Pali
<br />Cu Ft
<br />UUN3201Ragulatod Medical Waste, n.o.s,,
<br />6.2PGIl
<br />Cu Ft
<br />3, Generator's Certification: "i hereby declare that the contents of this consignment are fully and accurately TOT S
<br />Cu Ft
<br />ad above by the proper shippin name, and are classified, packaged, marked and labelled! ded, and
<br />in
<br />I respects proper conditio d'r transport a rding to applicable International and natio eve mental re ns"
<br />9rinledfTyped L� U1`���
<br />®s I l,f r)?
<br />Name�& Signature
<br />Dat
<br />ANSPORTER i ADD E
<br />Phone #:(B 3.7422
<br />w
<br />Ste r GyG er riG. This is a T roug hipment
<br />Applicable Permit Numbers:
<br />WM
<br />4135 W. Swift Ave
<br />Hauler Reg# 34170
<br />a
<br />FxennolCA 93722
<br />MW
<br />TRANSPORTS RTIFICATI - a ipt o teal waste as described abov
<br />J
<br />Prinll7ype Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #
<br />LY
<br />Applicable Permit Numbers,
<br />s
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/'lypo Name Signature
<br />Date
<br />W
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />xMa §,
<br />Applicable Permit Numbers:
<br />Mo
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Q�s
<br />—
<br />PrInt/Type Name Signature
<br />Date
<br />f DiW REPANCY INDICATION
<br />8A, Desigtintod Facility: 8B. Alternate Facility: 8C. Altemato Facility: BD. Alternate Facility:
<br />>
<br />, C. Steacycle, Inc. Stericycle, Inc.
<br />Covanta Marlon,lnc
<br />Q g
<br />4136 W, SWft AW 90 N. Foxboro Drive 1651 Shelton Drive
<br />4850 Brookiake Road NE
<br />refano, CA 83722 North Salt Lake, UT 84054 Hollister, CA 95023
<br />Brooks, OR 97305
<br />Z
<br />(866)783-7422 (801)936-1171 (866)783-7422
<br />(5115)393-0890
<br />1U
<br />TSIOST 22 I:?A(, ."E ofniz 3A -448/.3A 36 TSIOST 83
<br />Permit # 364
<br />a
<br />TR!?ATMENT FA I c rt It I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />11-
<br />received the abovdYlirtlicateivit 1�FA in accordance with the requirement outlined in that authorization,
<br />Prin*po Name . 13 n Signature
<br />Date
<br />1'fansferred containers, ou ti to
<br />
|