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MEDICAL WASTE TRACKING FORM NUMBER
<br />��� IN CASE OF EME GEN Y C NT T: CHEMTREC 1.809-424-9300 BTANDARD MANIFEST ooi-19-o85TD
<br />Stericycle' Rtrute�: �13EQi-'�� CUSTOMERN0.21132 MDRCOO�R�4
<br />1. Generator's Name, Address and Telephone Number
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<br />EMERALD�TATFfic7�tlP{ERCINC �III�I�IIII��illli�IIAI�II1�1�1�18�101aa�I�I'llllill
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<br />2525 S HUTCHINS 5T
<br />Gl18/2D21
<br />LODI, CA9524U-7146 (209) 578-1580
<br />8118197-002
<br />CUB1DMEq NuMeaq GENEpATOa'S REGISTgATION #
<br />2A.OESCRIPTION OF WASTE
<br />2e, CONTAINER TYPE
<br />2C. Na.OF
<br />2tl. VOLUME
<br />uN3291, Regulated Medical Waste, n.as,.
<br />TB14-(�) / TP 14-(�) 44 Gal Tub (5.8 cu ft)
<br />CONTAINERS
<br />8.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.os.'
<br />Tf321-(__)! TP15-(�) /TY15-O 28 Gal Tub (2.7)
<br />6.2, PGII
<br />Cu Ft.
<br />p
<br />fi23P�111RegulatedMedlcalwaste,n.os.'
<br />TB48-L_)/TP48-(,T,-)/TY48-(,)37GaITub(4.8)
<br />cu Ft.
<br />623PGII Regulated Medical Waste, n.os.,
<br />pg5__B Gal Tub (Bio)(3,6cu R)
<br />Cu FL
<br />W
<br />UN3291
<br />flegulated Medical Waste, n.o,s.,
<br />6.2,
<br />PGII
<br />Cu FL
<br />IZ
<br />�
<br />623p9G1i1 fle9ulaled Medical Waste, n.os.,
<br />Cu FI.
<br />UN3291, Regulated Medical Waste, n.os.,
<br />X43 -(_j / P1Ak13-(__) / Cy/4fj?.— ) 43 Gal 7uL- 5.7 cu R
<br />(-----• ( )
<br />6.2, PGII
<br />Cu Fl.
<br />623PGll Regulated Medical Waste, n.es.'
<br />KR_-BibsyaternS Cardboard Box (4.2 cu ft)
<br />Ft.
<br />cu
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6,2, PGII
<br />Cu FI.
<br />8. Generator's Cerllllcatl0n:'9 hereby declare Ihat the contents or this consignment are Wlly and accurately TOTALS ►
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<br />doscribed above by the prgper shipping name, and are classified, packaged, marked and IabelleNplacarded, and
<br />are in all respects in proper cVonditi or Iranspla/r/t according to applicable international and national governmen al reg tattoos."
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<br />Prinla ped Name F Q 1��1 h Tl iiL Signature ,
<br />Date
<br />4. TRANSPORTER 1 AbbRESS;
<br />Phone #; (86G) 783-7422
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<br />Stericycls, Inc. � Tltls t� o TiirOLtyii �)iiJ�iitBii!
<br />Applicable Permit Numbers:
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<br />11875 While Rock Rd
<br />3400
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<br />Rancho C dove, CA 5742
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<br />TRANSPORTER TIFICATI . Receipt of medical waste as descrl
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<br />PrinVrypa Neme Slgnalure
<br />Dale
<br />5. INTERMEDIAT HANDLER 2/TRANSPDRYER 2 ADDRESS:
<br />Phone N;
<br />��
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described abovo.
<br />PrfnVType Name 3lgnelure
<br />Dato
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<br />6.INTERMEDIATE HANDLER a/TRANSPORTER 3 ADDRESS:
<br />Phone q:
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<br />Applicable Pormil Numbers:
<br />INTERMEDIATE HANDLER/TRANSPORTERCERTIFICATION:Receiptelmedicalwasteasdascrihedabove.
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<br />PrinUrypa Name Slgnalure
<br />Dale
<br />7. DISCREPANCY INDICATION
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<br />.Osalgnated Facility: Ba.AHernate Fac19ty; � BC. AHernale Facility:
<br />[] aD.Allernafe Faclltty:
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<br />5t6A0J&�OIIb. (lgptt(�ilAtgfclave) 8tericycle, Inc. (Incinerator) 5tericycla, Inn. (Autoclave)
<br />Covanta Marian, Inc
<br />a �
<br />1814filaflimFton Dr g8 N. Foxboro Qrive 4135 W. aRAlift,�ve
<br />4858 BrnalJai<e Rnad NE
<br />F ��
<br />Yt�elplEtt�,4®IiglB023 North SaltLake, UT 84854 Fre�o, CA 83722
<br />Brooks, OR 87386
<br />422 22
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<br />Pe
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<br />T� 83 3A-4481JA-38 781057 22
<br />rc) t # 3 4g
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<br />TREAT QI��'T[Y,,•,� ��gqertify that have been authorized by the appllcabie state agency to accept untreated medical wastos and that I have
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<br />rece(ve�iAiflfAtl wastes i accordance with the requirement outlined In that authorization,
<br />PrinUType Na Slgnalure
<br />Date
<br />23 2�2 ra
<br />starred _ containers, =�_ cu It to : Yuba City, CA of
<br />resnD, CP,
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<br />sferTad containers, cu 8 to : N. Salt Lake, LIT or Fresno, CA
<br />� ___
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<br />Tra
<br />starred oDntainer� cu ft to : Brooke OR ar
<br />
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