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stericycle-
<br />�'� • N otecung leople. Redaring Risk
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />AASE OF EMERGENCY CONTACT. CHEMTREC 1-800.424- STANDARD MANIFEST 001.10.06 -STD
<br />Ttout e 4: 123 - 21 CUSTOMER NO. 21132 MDFROOJBVC
<br />1. Generator's Name, Address and Telephone Number E
<br />ATTN: j(
<br />�
<br />GILD 14KDICAL CrKHT R
<br />1617 Ii C;ALI.E'dSR-n2a ST
<br />STpf.K'LXeN, CA 9S204- 6117
<br />(20) 451-9031
<br />6/20/2017
<br />CUSTOMER NUMBER l},�,,i, �t`/ty S, GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TBi}S 4C �l T1 (1ir�jS_3 cut. ft)
<br />Cu Ft.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o s.,
<br />TR!g -� Gal Tub (Rio) (4.9 eta ft)
<br />Cu Ft.
<br />6.2, PGII
<br />(y
<br />UN3291, Regulated Medical Waste, n.o.s.,B
<br />4 4 Gal TUMBio) (5.9 CIA ft)
<br />Ft.
<br />6,2, PGII
<br />RCu
<br />Q
<br />UN3291 Regulated Medical Waste,n,o.s.,
<br />TB.21—fnXo)/TP15—$Fath TY15—fCbemo)20 Gal 'sub(*.7t;tr
<br />T)
<br />CC
<br />6.2, PGi1
<br />Cu Ft.
<br />tli
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />'� f �( ��_ f 1? dt]]} �(tp. t- f (jj jneYJ 31 Gal TUb (4..t§C
<br />T)
<br />W
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n o.s,,
<br />6.2, PGII
<br />W943^ 1Bit,) JpW43— (Pat1j) /C;w431_ (Chemo) Gal Tub(5.7CtIFT
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,o.s.,Y.itB
<br />6.2, PGO
<br />_ Friouli stems Y;.atrdboard sok (4_2 cru fti
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o s,
<br />6.2, PGII
<br />Cu Ft
<br />+
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />6.2, PGII
<br />Cu Ft
<br />3, rlerat is Certification: "I hereby declare that the contents of this consignment are fully and accurately T®ALS
<br />Cu Ft
<br />scribed a ove by the proper shipping name, and are classified, packaged, marked and labelled/pia rded, a d
<br />are In all re In proper condition for transport according to applicable international and natio v nm r lauons1
<br />tt
<br />/epts
<br />Pr€ eirfypea a " SI
<br />D:
<br />SPORTER 1 ADDRESS:
<br />St3LiCyr-"1t fIiC. ®Ttc1L5 3s a Tfiro gitrSINIpnert
<br />Phone#: (866) 783-7422
<br />Applicable Permit Numbers:
<br />W
<br />a+4175
<br />W. Swift ATIe
<br />HaulerReg# 3400
<br />0
<br />Freoao,M 93722
<br />< a.N
<br />a a
<br />TRANSPORTS +3 TIFI ATI : eceipt of medical waste as described above.
<br />r�
<br />°c
<br />PrinUiype Name ' Signature
<br />c
<br />Date
<br />5. INTERMEDIATE HANDLER 2/TA NSPORTER 2 ADDRESS:
<br />Phone #'
<br />C-4
<br />s
<br />Applicable Permit Numbers,
<br />no
<br />rarr cr�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />sw
<br />Applicable Permit Numbers:
<br />ul
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Q�x
<br />—
<br />Print/Typs Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />I
<br />Doslgnatod Facility.. BB. Alternate Facility: 8G. Alternate Facility:
<br />BD. Alternate Facility:
<br />Q
<br />StarlcyCle, Inc. Ste1icycla, Inc. StDrlcycie, Inc.
<br />41-4�r� 20 N. Foxboro DrWe 1651 Sheftn Dive
<br />�A93722 98023
<br />r
<br />F North SaltLak>re LiT 84!)5tl H>yfiistfr. C/1
<br />(BM783-7422 (Sk`6)783-7422 (M)783-7422
<br />TNS 2017 36 T.�MIr as
<br />Q
<br />tuPit!
<br />TREATMENT FAft(ITY12 certify that I have been authonzed by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/lype Name Signature
<br />Date
<br />raft rzi'YIG Coma nein r, CU ftto
<br />
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