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! 10® ®O Ste�"icycle! CASE OF EMERGENCY CONTACT: CHEiN7REC 1-800-424.
<br />• PmmNnghopleJUdudngRlsly CUSTOMER NO. 21132
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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10.00 -STD
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number tut! x�atl �,x
<br />C7TLL MDICAL C,'Z 1TLEt
<br />1ta'17 'N CALMEORRIA ST
<br />S i'T'1.00.'MIN, CA 95204- 6117
<br />CUSTOMER NUMBER GENenmon•s REGISTRATION #
<br />2A. DESCRIPTION OF WAST
<br />CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s ,
<br />CONTAINERS
<br />6.2, PGII
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ! ° Cu Ft
<br />d d above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />onjitlonn for transport according o(�a/p►plicable international and natl gov nmental regulations"
<br />re In expects In proper cyt—"
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<br />ted/Typed NamaIV
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<br />NSPORTER 1 ADDRPhoneLLJ #
<br />r Steftcycle, itlt_ , Ttds a.s a Through Shipment Applicable Pmt I50rnn11ir3--7422
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<br />4n- 5 W. Swift Ave
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<br />Hauit+>= Ftc-*g# 3400
<br />Fraena CA 9 722
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<br />TRANSPORTER RTIFICXT101\1: Re ipt of medical waste as described a e
<br />(J�j,' 1
<br />Printrrype Name Signature Date L
<br />5. INTERMEDIATE HANDLE 2 /TRA SPO TER 2 A RESS: Phone #.
<br />sApplicable
<br />Permit Numbers:
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<br />N EI
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />—
<br />PrInVType Name Signature Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #
<br />Wo w
<br />J
<br />Applicable Permit Numbers,
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />—
<br />Pr(nt/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Fa¢flily: 89. Alternate Facility: 8C. Alternate Facility: ❑ 8D. Aftemate Facility:
<br />In . z Steri cycle. Inc.
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<br />�t q NcFax3at QtMa iS &# SfitaIt+xt� Drt
<br />Fresno.CA 93722 M01th, Salt Lath's, UT 84054 Hollister. CA 95023
<br />U.1 111,4
<br />(886 7x3- >< M)783- 422 (8%')783-7422
<br />P2017
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<br />aA-44 36 TSfosT 8a
<br />TREATMENT h°ACILITYeJ certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the above indiWted wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />V- ?`raasfalrred lowdafaam, cit ti to
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<br />ORIGINAL
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