|
MEDICAL WASTE TRACKING FORM NUMBER
<br />• & r STANDARD MANIFEST 001 -10.06 -STD
<br />®®®O S4e`ricycle, � a?F �pE G VCY COJ*CT: CHEMTREC 1-600-420
<br />®® Ttoteetregpeople.RedudogRlsk: CUSTOMER NO, 21132 MDFROOJOX7
<br />I
<br />1. Generator's Name Address and Telephone Number
<br />;�TTK . 11
<br />It j! !1 t! 1111 II 1t If
<br />MLL MM:EC,RL C'E21WL."Ft
<br />1517 'N CAL-IFOFtIffA ST
<br />STOMT01, CA 95204— 15117
<br />(205) 451--9031 5/30/2017
<br />I
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and acc ately TOTALS 1�
<br />desc d Bove by the proper shippin nd ara classified, packaged, marked and labelled/p a ed, and
<br />n all r pacts In proper co ti or transp rt according to applicable international and natio g v rnmental regulations:'
<br />Cu Ft.
<br />Cu Ft.
<br />6111852-001
<br />��
<br />1� U �l��r� " I
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />I
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />4
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />THOS 4f) Gal Tub (Biu) (5.3 ecu ft)
<br />4135 19. Swift: Attar
<br />6.2, PGII
<br />i
<br />I!
<br />UN3291,Regulated Medical Waste, n.o.s.,
<br />2329
<br />a Osx
<br />I
<br />Fr
<br />Z
<br />X
<br />UN3291. Regulated Medical Waste, n o s,,
<br />iYal wil zffrvF7au ttp
<br />®
<br />6.2, PGI[
<br />Signature
<br />UN3291Regulated Medical Waste, n.o.s.,
<br />91
<br />"
<br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />6.2, FGli
<br />HApplicable
<br />W
<br />UN3291, Regulated Medlcal Waste, n.o.s.,
<br />a i erncv ., '334 T55(4.
<br />Z
<br />6.21 PGII
<br />U3
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />anal Tub (5.7c
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />6.2, PGII
<br />a
<br />UN3291, Regulated Medical Waste, rix.s.,
<br />Eaw�.. --yriosystems Cardboard Box (4 21 cu fir)
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />6.2, PGII
<br />Printtrype Name Signature
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />6.2, PGIf
<br />UN3291, Regulated Medical Waste, %0.2.,
<br />R 0 prll
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and acc ately TOTALS 1�
<br />desc d Bove by the proper shippin nd ara classified, packaged, marked and labelled/p a ed, and
<br />n all r pacts In proper co ti or transp rt according to applicable international and natio g v rnmental regulations:'
<br />Cu Ft.
<br />Cu Ft.
<br />1 17. DISCREPANCY INDICATION
<br />I'M
<br />8A. D s gnpted Fpcillty: ❑ 8S. Alternate Facility: E] 8C. Alternate Facility: ❑ 8D. Alternate Facility:
<br />Rw Ia. Inc. stertcyde. W. �rtcycte. Inc.
<br />W. SWIltM 90 N. Ffrx mt Drava 1551 Shabn Drio
<br />Fresno OFM North Silt Lake. UT 840% Hollister,;OA 95023
<br />(a 6)
<br />dP (86%)M3-7422 (Smikk7
<br />3A 18.1A -itis TSIOST 83
<br />MAY 3 0 2017
<br />TREATMENT FACII;I�SgQity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above h cat`U;Nastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signa.,rtur _ Dale
<br />FiiIIl � ec .w
<br />'ORIGINAL
<br />`
<br />��
<br />1� U �l��r� " I
<br />i (Print d/lypad Na (gnat
<br />x
<br />Q.TRA ORTER 1 AD.t�
<br />�yi le, (tit`., ® This i.a a Tt rpugh Shipmerrt
<br />Phone #. y y—
<br />4135 19. Swift: Attar
<br />Applicable Permll Numbers
<br />a
<br />aQ
<br />Ezevno,CA 937.22
<br />Hauler Regis 3400
<br />n c.
<br />Fr
<br />Z
<br />TRANSPORTE RTI IC IP Receipt of medical waste as describ bove
<br />/y/y�
<br />r /--kt 2
<br />Printfrypa Name L-t`�'
<br />Date
<br />Signature
<br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />HApplicable
<br />Permit Numbers:
<br />a go
<br />N x
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Printtrype Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />a
<br />Applicable Permit Numbers*
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printtrype Name Signature
<br />Date
<br />1 17. DISCREPANCY INDICATION
<br />I'M
<br />8A. D s gnpted Fpcillty: ❑ 8S. Alternate Facility: E] 8C. Alternate Facility: ❑ 8D. Alternate Facility:
<br />Rw Ia. Inc. stertcyde. W. �rtcycte. Inc.
<br />W. SWIltM 90 N. Ffrx mt Drava 1551 Shabn Drio
<br />Fresno OFM North Silt Lake. UT 840% Hollister,;OA 95023
<br />(a 6)
<br />dP (86%)M3-7422 (Smikk7
<br />3A 18.1A -itis TSIOST 83
<br />MAY 3 0 2017
<br />TREATMENT FACII;I�SgQity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above h cat`U;Nastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signa.,rtur _ Dale
<br />FiiIIl � ec .w
<br />'ORIGINAL
<br />
|