Laserfiche WebLink
MEDICAL WASTE TRACKING FORM NUMBER <br />O® *O stericyc,le- --WCASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424- OD STANDARD MANIFEST 001 -10 -06 -SM <br />• PcatactlrgPeopit.Rciludniikitk: Rouge -N: 123 - 14 CUSTOMER NO. 21132 <br />1. Generator's Name, Address and Telephone Number <br />ffgm <br />111111 loll 111 <br />GILL Y'fmcAxL` G' 4TEFt <br />1617 to cALIFORtiIA ST <br />STOCKTO'N, CA 95204- 6117 <br />t2091 451-9031 7t:'J;12A17 <br />CUSTOMER NUMBER 61.1- <br />2A. DESCRIPTION OF WASTE <br />UN3291 Regulated Medical Waste, n.o s <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n,o.s <br />6.2, PGII <br />O6.z <br />3229911t Regulated Medical Waste, n.o.s <br />4 UN3291, <br />x 6.2, PGII <br />W UN3291 <br />1111 <br />6.2, PGI) <br />a UN3291 <br />1i6.2, <br />6 231`1311 <br />waste, n os , <br />Waste, n os., <br />Waste, n.o.s., <br />GENERATOR'S REGISTRATION # <br />LINER TYPE <br />TB49 - 37 Gal Tub (Elri0 (4.9 cu f1~) <br />TH14 - 44 Gal Tub(Bi*) (S.9 au ft) <br />T821- (RIG) /TP35- (Path) ITY15- 41,%erno) 20 Gal TUb (2.7c <br />tiWB33- <br />Waste, n o.s., <br />KR]3 <br />Waste, n.o s.,-� <br />Waste, n.0.s , <br />3. Generator's Certification: °I hereby declare that the contents of this consignment are fully and accurately TOTALS ► <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are In all respects In proper condition for transport according to applicable international and national governmental regulations" <br />1\Y' vt I _ . . . . A . .. . , <br />a 4. TRANSPORTER 1 ADDRESS: <br />a Lu Stecicycle, Inc. <br />4135 W. Swift: Ave <br />aCn reesna,(,'A 93722 <br />This ±,3 a Through Shi mterrt <br />a a TRANSPORTER CERTIFICATION: g Vcelpt of medical waste as described above <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRE=SS: <br />N <br />Win <br />U)' INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />PnnMpe Name Signature <br />2C. NO. OF 2D. <br />CONTAINERS <br />Date 01 <br />VOLUME <br />Phone #: g <br />Applicable �rfYiif drlMrs3422 <br />3 aulear Reg# 3400 <br />Date <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />Cu <br />na <br />aw <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. <br />Phone 9. <br />Applicable Permit Numbers: <br />J <br />N <br />a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />fE <br />Print/Type Nemo — <br />Signature <br />Date <br />7. DISCR NCY INDICATION <br />8A. Designated Facility; <br />❑ 8B. Alternate Facility: ❑ 8C. Alternato Facility: <br />0 8D. Alternate Facility: <br />v <br />Stiertcycie, Inc. <br />S aricycle, Inc. tricycle, Inc. <br />4 <br />LL <br />41J�A , t 6WIZ <br />SO N. Fox6ana DrNa 1551 Shelton Drtvzi <br />i+reario,CA 53722 <br />North SaaltLake, LT 840 1 Hollister, CA 95023 <br />(866)783-742.2 <br />tsJ9 5 <br />(856)783-7422 (865)783-7422 <br />2017 <br />a, t a. TS/CLa"T 83 <br />TREATMENC%yLg2y 1 certify <br />that I have been authorized by the applicable state agency to accept untreated <br />medical wastes that I have <br />c <br />received the above 115liNated <br />wastes in accordance with the requirement outlined in that authorization. <br />and <br />PrinI/Type Name <br />Signature <br />Date <br />Transferred containers, tau it to <br />I <br />ORIGINAL <br />