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MEDICAL WASTETRACKING FORM NUMBER I
<br />O�ao Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC t-aee-424-9300 STAN*;; MANIFEST 1.0321-NOCA
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<br />• 6 e Roule 702-11 CUSTOMER N0.21132 Ft
<br />1. Generator's Name, Address and Telephone Number
<br />EMERALDS TATTOO &PIERCING
<br />2525 S HUTCHINS ST
<br />11115/2021
<br />LOUT, CA95240-7146 (209) 578-1500
<br />6118197-002
<br />CUSTOMEn NumsER GENENAwars RecasTSAT1oN #
<br />2A, DESCRIPTION OF WASTE
<br />2B, CONTAINERTYPE
<br />2C, NO, OF
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n.os,
<br />TB14-(Bio)�TP14-(Path) TY14-(Incinerate)_ 44 Gal. Tub
<br />C NTAI ERS
<br />5._Cut
<br />6,2t Po
<br />cu Ft.
<br />823PG11
<br />Regulated Medical Waste, n.o.s.,
<br />TI321-(Bio)_—TP15-(Path) TY15-(Chemo)_20 Gal. Tub (91
<br />ClfL)
<br />Cu Ft.
<br />T849 -(Bio -(Chem )_ T149 -(Incl _ eej_ 37Gal. TLb(4,0Cuff.',
<br />p
<br />6.23P6illRegulaladMedlcalWasq,n,os.'
<br />__
<br />Cu FL
<br />Metllcal Waste, n.os.,
<br />623 PGII
<br />\Ar8,-(Bio)_CV\AJ2-(Ch/ mo)tAY-(Phann)_43Ga1. TLb(5.7CuIt.)
<br />Regulated
<br />Cu Ft,
<br />623PGII
<br />Regulated Medical Waste, n.es.'
<br />KR (Bio)_ Gal. ConlpatedB (4.32 Cuff,)
<br />cu Ft.
<br />IZ
<br />Vr
<br />UN3291
<br />Regulated Medical Waste, mo.s.,
<br />6.2,
<br />PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, mo.s.,
<br />6.2, PGII
<br />/
<br />Cu Ft.
<br />623 Gil
<br />Regulated Medical Waste, n.o.s.,
<br />/
<br />Cu Ft,
<br />UN3291
<br />Regulated Medical Waste, mo,s.,
<br />6.2, PGII
<br />Cu Ft,
<br />3. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately TOTALS ►
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and laballedfplacarded, and
<br />are In all respects In proper condition for transport according to applicable International and national governmental regulatlons"
<br />Printe lRyped Name Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone Ili (209) 294-7114
<br />m
<br />Stericycle, file. F This is a Through Shiptttettt
<br />Applicable Permit Numbers:
<br />PC
<br />7375 R A Brfdgeford Rd.
<br />TS/OST-80
<br />2
<br />Stockton, CA 95206
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<br />CL q
<br />TRANSPORTER CERTIFICATION: Rece p t of medical waste as described above.
<br />^fj
<br />Dale
<br />nLL Signature
<br />PrinUrype Name
<br />5. INTERMEDIATE HANDL&12 ITRANSPORT ADDRESS:
<br />Phone e:
<br />`V
<br />Applicable Permit Numbers:
<br />x
<br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />-
<br />PrinVryps Name Signature
<br />Date
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />E0g4 q
<br />Applicable Permit Numbers:
<br />11
<br />F2rj
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste asdescribed above.
<br />Prinviype Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION
<br />$
<br />❑ 6A, Designated Facility: ea. Al emate Facift E] BC, Alternate Facility:
<br />❑ so. ANamate Facility:
<br />0Stericycle,
<br />Ina (Autoclave) Stericyole, Inc. (Incinerator) Stericycle, Inc. (Autoclave)
<br />Covanta klarien, Ina
<br />a PM
<br />7375 RA Bridgeford Rd. 90 N. Foxboro Drive 2775 E.26d1 St,
<br />4550 Brouklake Road k1E
<br />LL
<br />Stockton, CA 05206 North Salt Lake, UT 84054 Vernon, CA 90058
<br />Brooks, OR 97305
<br />(200)294-7114 (801)936-1171 (066)703-7422
<br />(505)303-0090
<br />TS/OST-9u 9A-19E/JA-36
<br />Permit$984
<br />a
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />a
<br />F- •
<br />received the above Indicated wastes In accordance with the requirement outlined in that authorization.
<br />g
<br />Prinl/rype Name Signature
<br />Date
<br />ORIGINAL
<br />
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