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<br />• ProtectdigPe%Ia,aed.ftWsk: it t3 � x'73 -- �. CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10-06•STD
<br />[ 11111011111.1
<br />1. Generator's Name, Address and Telephone Number
<br />ATTU s
<br />GILL 14&'DICAL CEit`1'Lf'd
<br />'16 L7 -N C2kLIFORI'l'3:A ST
<br />ST(1CI9'.111, f,A. 95204- 6117
<br />'tltita x.51-9031
<br />4/11/2017
<br />CUSTOMER NUMBER 671-11652-001 GENERATOR'S RBGISTRAMON #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAiNERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN3291 Regulated Medical Waste, n,o s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, It o.s.,
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<br />6.2, PGIIoe:
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<br />6.2, PGI
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T22 -1–=O) TP35– (Pat])) /TY15– tCt 31eank)) 2 Gal Tub (^.7Cit
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<br />6.2, PG11
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<br />UN3291 Regulated Medical Waste, mos,
<br />WB31- (Bi*)IWP31– (Pakli)/Ist.31- (r1)leano) 31 Oal Tub (4.14CU
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<br />62, PGi1
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<br />623PGljRegulated Medical Waste, n.o.s.,
<br />WH42-(Bir,)%P'W43-(Pat3i)JCW42-(Chemo) Gal Tubt5_7CUFT}
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />K" - Biosystems Cardboard Box (4.2 k -)a -ft)
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Cu Ft
<br />6 2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
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<br />3. Gene tar's Certiflcatlon: "I hereby declare that the contents of this consignment are fully and accurately T®TALS
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placard d, and
<br />n II r pects in proper condition for transport according to applicable international and net! ver me i r gulations"
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<br />PrizeMped Name V S1g
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<br />4. SPORTIER 1 ADDRESS-
<br />`a Q Ttds is a Ttaruugt� t3hiy�raeTtt
<br />Phone # ($£,6) 703-7422
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<br />1:eL'3i."+t�%t�, i4c.
<br />Applicable Permit Numbers:
<br />4L35 14III:. swift Arne
<br />33auiiaat: Reg# .400
<br />2 a
<br />RTIFiC
<br />r, re-axw,,t,A. 93722
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<br />TRANSPQRTE N: Receipt of medical waste as des ed a
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<br />F'
<br />Print/Type NameSignature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #
<br />rcw
<br />Applicable Permit Numbers:
<br />SAx�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above
<br />4�z4�i
<br />F
<br />Print/i"ype Name Signature
<br />Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />acc
<br />a
<br />Applicable Permit Numbers
<br />N a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt Of medical waste as described above.
<br />.1 x
<br />–Print/7ype
<br />Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />A. Dosl natyd Facility: Be. Alternate Facility: ❑ IC. Alternate Facility:
<br />81). Alternate Facility. f
<br />11
<br />Stericycle, Inc_ Staricycle, Inc. S tricycle, Inc.
<br />4135 W, 9eAAva 90 N, Foxboro Drive 1551 Sftt hftn Ditve
<br />I'reban fZ Worth Safi Lake, Ur 84M CA 95023
<br />(86
<br />1mo"
<br />Uj
<br />(868)783-742V (86'15)783-7422
<br />TStaT 3A-r#48,lA-38 TS10BT83
<br />a
<br />APR 112017
<br />WN
<br />TREATMENT FACILITY: i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br />i-
<br />received the abdb*, dic&ed wastes in accordance with the requirement outlined in that authorization
<br />Print/rype Name Signature
<br />Date
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<br />[ 11111011111.1
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