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<br />'— MEDICAL WASTE TRACKING FORM NUMBER
<br />V Steric 1iC �* ASE O�YEMERGENCY CONTACT: CHEMTREC 1-800.42 STANDARD MANIFEST 001 -10 -06 -STD
<br />,,77 outs 123 — 21 CUSTOMER No. 332 MDFROOKFUT
<br />'(.
<br />and Telephone NumberA
<br />Generator's Name,
<br />T�Address
<br />iI 1[ f(
<br />11 jl
<br />GILL 1<+i DI M my=
<br />1617 N CALIFUMA ST
<br />SIY.>t.71;TON, CA 95204— 6117
<br />(209) 451-9031
<br />4/10/2018
<br />GuxWMFaNuMoEn (5111852-001 2—x}01 GENERATOR'sREGISTRATION 4
<br />2A.f)E5CR1PTIONOFWASTE
<br />28. CONTAINERTYPE
<br />2C. NO, OF
<br />20. VOLUME
<br />UN3291, RoaulalCd MedlcalWaste, n,o,s„
<br />6,2,.PD7t
<br />T804 – 28 Qat Tub (Bio) {3.? cu ft}
<br />CONTAINERS
<br />Cu Ft.
<br />G -Z Pali Regatat8d Medical Waste, Tt.os.,
<br />TB4 9 _ 37 Gal. Tub {Bio} (4.9 cu ft)
<br />Cu Ft.
<br />ps29t, ReiiWateJ Medical ftia,n,o.s.,
<br />TBl# 44 Gal Tub (Bio) (5.9 Cu ft)
<br />Cu Ft.
<br />0, poll
<br />v
<br />ii
<br />G..3PGiI Regulated hlodlcat Waste, rims.,
<br />TB21– (,_,__„) /TPi5– () /TY15– () 20 Gal Tub (2.7COFT)
<br />Cu Ft.
<br />w
<br />Utl's291, Reptllated MCdlCal Waste, U.S.
<br />1321 V81
<br />Cu Ft
<br />Ula
<br />Ali Regulated Modica' WEte,110.s„
<br />B PGIi
<br />btBsal 43– { ) JWP43– { ) /tilCd3– { ) stub (5. ?CiJE'T)
<br />Cu Ft.
<br />t)N329t.T�sgulated Medical Wasto.'n.a s
<br />S."� poll
<br />KR _ Bi.o stems Cardboard Box (4.3 au ft)
<br />Cu Ft.
<br />llN'd29i Rcpulated MoUIV W4,1:4, rl ia,s„
<br />6.2, poli
<br />Cu Ft
<br />UNS291, Rogolaisd Medical'WASt% D.a,s.,
<br />82. t7lall
<br />Cu Ft
<br />2.00n e's Certification, °I hereby declare that iha contents of this consignment are fully and accur T LS �"
<br />Y
<br />+- Cu Ft.
<br />r9rtvc �d bye by the proper shipping nam©, and are classified, packaged, merited and labelle r and
<br />n a ,r!sis In propor condition for transport according to applicable m rnational and io a regulatio
<br />XV
<br />f –%
<br />PrinNorrta
<br />ORTER i ADDRESS:
<br />StFaticycle=', Inc. Thi- a .ugh Shipment
<br />Phone N: (86 3-7422
<br />Applicable Permit Numbers:
<br />X
<br />4135 W. Swift Ave
<br />Hauler Reg# 3400
<br />Fteieino,CA 93722
<br />e
<br />TRAN$PORTER TiFt CATi - e elpt of me at waste as descnbe hove
<br />Date
<br />Pdnb'Type Namo Signature
<br />S. INTSAM-EDfATE 0ANdt-W WRANSPORTER 2 ADDRESS:Ric)
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />"PdiAnwa Name Signature
<br />Date
<br />a, INTERMEDIATZ HANDLER 3ITRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />�u
<br />Applicable Permit Numbers:
<br />�
<br />INTERMEDIATE HANDIER /'TRANSPORTER CLRT(FICATtON: Receipt of medical waste as described above.
<br />–
<br />P*ttlfyp* Namur Signature
<br />Date
<br />7x15ISCREPAN4Y INDICATION
<br />A, Peslgnafod F011tyt se. Altornato Facility: E]8C. Alternate Facility:
<br />aD. Alternate Facility:
<br />t
<br />, Inc. Staricycle, Inc, Stericycle, Inc,
<br />Covanta Marlon,inc
<br />cy
<br />4136W.SMAV4 90 N.FoXbO a Drtve 1551 Shelton Drive4860
<br />Brooklake road NE
<br />Prenno, CA 9372 Naito Sat Lake, UT 84054 Hollister, CA.95023
<br />Brooks, OR 97305
<br />(868)70-7422 (801)93& 1171 (85fi)M7422
<br />(505)393.8890
<br />TWST-22 MEMOMoff r�Z3A-448136 MOST -83
<br />Perml# 364
<br />t
<br />r�ipet (have been authorized by the applicable state agency to accept untreated
<br />'T#iF,.A'TFA>~NTi~Adig�l
<br />received the; ibov6°indtcated wastes in accordance with the requirement outlined in that authorization.
<br />medical wastes and that 1 have
<br />pt9rftwe Name +�'� _ Signature
<br />Date
<br />Transferred containers, caul A to
<br />
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