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MEDICAL WASTE TRACKING FORM NUMBER
<br />e �a's Stencyclee IN CASE OF EMERGENCY CONTACT: CHEMTREC I•SOa424.9300 STANDARD MANIFEST 001•e341,NOCA
<br />Rouie* 703-21 CUSTOMER NO, 21132 MDTK000CE1
<br />1. Generator's Name, Address and Telephone Number
<br />AVanessa Aguilar I (N I I II++ I I t
<br />EMERALDS TATTOO & PtERCIN6
<br />2525 S HUTCHINS ST 213/2022
<br />LOD], CA95240-7146 (209) 578-1550
<br />6118197-002
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION H
<br />2A. DESCRIPTION OP WASTE
<br />2B. CONTAINERTYPE
<br />2C, NNOA.IOOF
<br />2D4 VOLUME
<br />623291, Regulated Medical Waste, n,o,s„
<br />TB14-(Blb) TP14-(Path)`TY1Q(Incinerate)_ 44 Gal. Tub
<br />PiCIIGUn)ERS
<br />Cu Ft.
<br />UN3291 Regulated Medkal waste, n,o.s„
<br />TB21-(Bio).,TP15-(Path),_.-,_TY164Chemo)�,20GaI.Tub(27CuR.)
<br />Cu
<br />6,2, PGII
<br />Ft.
<br />cc
<br />UN3291 Regulated Medlcal Waste, Ras,,
<br />TB40_(Bio)__TY49-(Chemo)
<br />(4.9Cuft.)
<br />.TI49{Incinerate),�37Gal,Tu
<br />Cu A.
<br />UN3291 Regulated Medical Waste, n.os.,
<br />Phar .
<br />YU'{ ) ( ) ( )—^^,43 GalTu
<br />WX43-ChemoB43 Bio
<br />( 5 .7Cuft.)
<br />6.2, PGI,
<br />_CW43- —_m
<br />Cu FI.
<br />s23PG1IRegulated MetllcalWaste, n.os.,
<br />KR^(Blo)Gal, Corrugated Box (4,32Cuft,)
<br />Z
<br />Cu FL
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Fl.
<br />623291, Regulated Medical Waste, n,os.,
<br />Cu Fl,
<br />UN3291, Regulated Medical Wasta, n.o.s.,
<br />6,21 PGII
<br />Cu FI,
<br />UN3291, Regulated Medical Waste, n,o,s„
<br />6.21 PGII
<br />Cut
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ► %f9Z Cu FI,
<br />described above by the proper shipping nems, and are classified, packaged, marked and labelled/placarded, and
<br />are In all respects in proper condition for trans'poortt according to applicable International and national govern ntal regulau '
<br />Printedr/T ped Name — "" SIgnatI4,44 Date
<br />4. TRANSPORTER I ADDRESS: Phone W:(2Q9) ZU4.1114
<br />w
<br />Stericycte, Inc. E ❑ This is a Through S Ipnient Applicable Permit Numbers:
<br />7875 R A Bridgeford Rd. TS/OST-80
<br />H
<br />Stockton, CA 95206
<br />a q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as descrlb ove.
<br />Prinl/ryps Name Cd IIA Signature ��'i ` --'- - Date _ Q
<br />6, INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 0:
<br />Applicable Permit Numbers: ,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />w
<br />q�
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />�u
<br />Applicable Permit Numbers:
<br />51
<br />20
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />a�a:
<br />�-
<br />Printriypa Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />y
<br />SA. Unit; II eB. ARemere Faclluy: SC. Alternate Facility: aD. Alternate Facility:
<br />ric"E j�NAN teriDycle, Ino. (Incinerator) Stericyole, Ino, (Autoclave) Covanta Marion, Inc
<br />7875 RA Bridgetnrd Rd, N. Foxboro Drive 2776 E, 26th St, 4850 Brooklake Road NE
<br />uUa
<br />I
<br />StocktonFROW932022 t orth Salt Lake, UT 84054 Vernon, CA 90068 Brooks, OR 97306
<br />l'"
<br />(209)294-7114 ( 01)930.1171 (806)783-7422 (605)393-0890
<br />TSK)ST�-80 A-446/JA-36 Pernat# 304
<br />i
<br />TREATMENT FLITey
<br />Ytify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />F-^
<br />receive accordance with the requirement outlined in that authorization,
<br />Printrrype Name Signalure Date
<br />ORIGINAL
<br />
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