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MEDICAL WASTE TRACKING FORM NUMBER
<br /> t:iP Stericycle® 1 V R�(aE$F Ef�I5VENCY gONTACT:CHEMTREC 1.800-424-9300 STANDARD MANIFEST 001.10-os-STD
<br /> ' 1r 17v CUSTOMER NO.21132 MDEROOLTOS
<br /> 1.Generator's Name,Address and Telephone Number l` BONN
<br /> ATTN:CrysW Molirwl
<br /> VAN TRAM, DR RUCK DDS INC.
<br /> 1007 S NM ST
<br /> 109MCA, CA 95337-5703
<br /> (209) 823-9218 4112/2019
<br /> CUSTOMER NuFABER (3084572-001 GENERATOR'S REGISTRATION A
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C, NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.O.S., 1111M—28 Gal Tub (Bbf `3,7 cu 9 " ' CONTAINERS
<br /> 6.2,PGII Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.os., TNO-37 tial Tub (Bio)(4.9 cu 2)
<br /> 6.2,PGI! Cu Ft.
<br /> OUN3291,Regulated Medical Waste,n.b,s., T814-4j Gal Tub(Blo)(5,9 cu 9)
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<br /> UN3291,Regulated Medical Waste,n.p.s,, Cu Fl.
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<br /> 62,PGII�Regulated Medical Waste,n.ps., WB434--- M1P43-(_)/WC434---)Gal Tub(5.7CUM Cu Ft
<br /> 6.2,PG(f Regulated Medical Waste,n.as., KR`-Bioswlems Cardbpmv!Do(4,3 cu 0) Cu Ft.
<br /> UN3291,Regulated Medical Waste,n.o.s.,
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<br /> UN3291,Regulated Medical Waste,n.o,s.,
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately 707ALS ► Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarde , d
<br /> are in all re cis i proper condition for tr nsport according to applicable International and national gover m tat re ti s:'
<br /> Print Signature Date
<br /> a 4,TRANSPOR Phone fuz
<br /> -
<br /> w Inc. ❑ This IS a hraugh CI1i Applicable Permit umbers:
<br /> 4135 W. dii l Ave aukr Re 3408
<br /> 2 A Fres 2272;
<br /> (!1 -�
<br /> a Z TRANSPORTE RTI CAT : Receipt of medical waste as described v .
<br /> PrinLrrype Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTS ADDRESS: Phone#:
<br /> N
<br /> wQ Applicable Permit Numbers:
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<br /> iRm Z
<br /> INTERMEDIATE HANDLED/TRANSPORTER CERTIFICATION: Recelpt of medic twas as described above.
<br /> a
<br /> Print/Type Name Signature Date
<br /> LU 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Xo W Applicable Permit Numbers:
<br /> N a a INTERMEDIATE HANDLED/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> aZ
<br /> cc Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> r
<br /> } c A. OVA 8B.Altemate Facility: BC.AHarnate Facility: 8D,Alternate Facility:
<br /> �—� Ste Ta;Inc.(Autoclave) ,Inc.�lnclner�ar� SEorfcycle,Inc.(Autodeve) Covsnta Marion,Inc
<br /> s 4135 W,SWR A N, �04cEoro rk 1651 SI'Mibon DOA 4860 Smoklake Road NE
<br /> a r�,.r.�.,, 2 a"La",Lr�r 24W , ,cr,ft�a eroolta,OR 9730E
<br /> IL � (tlaafts>�z jdC1�-1171 (866)7$3-7432 (105) SIM890
<br /> N TSMT 22 �� 3A•448/JA-36 TWOST 83 Permit#364
<br /> Q 1.1
<br /> LU o 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— A received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> PrinUType Name MAN Si n ture Date_
<br /> Tran:Nmrd taarltalntrs, cu R to ,N.Sa! Lain, UT
<br /> ORIGINAL
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