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MEDICAL WASTE TRACKING FORM NUMBER
<br />i � i� Stericycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC d-800.424-9300 6TANDARD MANIFEST OUhiU�os-STD
<br />Route �: 036 -12 CUSTOMER N0.21132 MDRCDOSCIH
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<br />1. Generator's Name, Address and Telephone Number
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<br />ATTN: Vanessa Agwlar �� I I II
<br />II I u uu �IV
<br />I � ��I I II'II'llll I I �� � II
<br />EMERALDS TATTQO 8 PIERCING II�III'll'�I
<br />!� 111111
<br />2525 S HUTCHINS ST
<br />3l2Cr(2021
<br />LODI, CA 95240.7148 (209) 578-1580
<br />CUSTOMEa NuMBEa 6718197-D02 GENEaATOWS REGISTNATH)NA
<br />2A. DESCRIPTION OF WASTE
<br />2e. CONTAINER TYPE
<br />2C. NO: OF
<br />2D, VOLUME
<br />UN329I, Regulated Medical Waste, n.os.,
<br />TI314- / TP14- 44 Gal Tub 5.8 cult
<br />CONTAINERS
<br />8 23PG11I
<br />ReOulated Medlcal Waste, n.os.,
<br />TB71-(�) / TP1b(^) / TY15-(_) 20 Gal Tub (2.7)
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<br />UN329I. Regulated Medlcal Waste, n.as.,
<br />�q8-(_) J TP49-(_„_,) / TY49-(^_) 37 Gal TUb (4,9)
<br />�
<br />6.2, PGII
<br />Cu Ft.
<br />623Pa�I Regulated Metlical Waste, n.os.,
<br />'fB35 - 2B Gal Tub (BtD) (3:5 cu ft)
<br />Cu Ft.
<br />W
<br />UN329I
<br />Repulaled Medlcal Waste, n.o.s„
<br />6.2,
<br />PGII
<br />Cu FI.
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<br />623PGII Repulaled Medlcal Waste, n.o.s.,
<br />Cu FI.
<br />s 23acrll Reputated Medical Waste, n.os.,
<br />WB43-(^) J PW43-(_,) y �W4�(�--..) q3 Gal Tub (fi,7 t�
<br />ft)
<br />cu Ft.
<br />UN329I Regulated Medlcal Waste, n.os,
<br />5.2, PGII
<br />KR^ - Biosystems Cardboard Bnx (d.2 cu ft)
<br />Cu Ft.
<br />B 23PGII Regulated Medical Waste, n.o.s.,
<br />�
<br />Cu FI.
<br />3. Generator's Certilicatlom "I horeby declare Thal the contents of this consignmonl aro fully and accurately TOTALS
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<br />described above by the proper shipping name, and are classiflod, packaged, marked and labelled/placarded, and
<br />are In all respects In prnper cond,,lt'lfon for Imnsl/plo�rt ascot-rsding to appllcable International end national governm fat re latiens:'
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<br />Pdnledrryped Name W ` Slgnature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, IfIC. X❑ This is ThrOUgll hipmeni
<br />Phane g:
<br />Applicable Permit Numbers:
<br />11�78'tt."i;�tt: Reek Rd
<br />3400
<br />� °
<br />Rancho C CA 742
<br />,
<br />TRANSPORTER RTIFICAT : Recalpt of medical waste as describe o
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<br />PrinVrypo Neme r Slgnature I �
<br />22 /�
<br />Date �.0 -(2 Q
<br />6. INTERMEDIA HANDLER 2/TRA SPORTER 2ADDRESS:
<br />Phone q:
<br />Q �
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recalpt or medical waste as described above,
<br />PrinVryPe Name Slgnature
<br />Date
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<br />6. INTERMEDIATE HANDLEfl 3/TRANSPORTEfl 3ADDRESS:
<br />Phone H:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLERlTRANSPORTERCERTIFICATION:Receiptofinedicalwasteasdescribedabove,
<br />PrinVlype Nama Slgnature
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<br />7. DISCREPANCY INOICgTION
<br />neelynetad Faclllry;
<br />sa, Allemele Facility: �eC. Alternate Facility:
<br />�90.Allerneta Facility:
<br />S�C�, I���CI0V8)
<br />,StedCYCle, Inc. (Incinerator) Sterioycle, Ino. (Autxlave)
<br />Covattta Marion, IDD
<br /><
<br />i�g4Yon 4r
<br />90 N. Foxboro Drive 4135 W. Swift Ave
<br />48517 Brooklake Road NE
<br />a
<br />� �
<br />Ybb{f1014�CAi$150�23
<br />Nnrlh SahLake, lit 84954 Fresno, CA 93722
<br />9rooks, OR 973175
<br />(5;8�6Q57�422
<br />(801)038-1171 (888)7$37422
<br />(5p5�'930$99
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<br />T3S)r9611983
<br />3A-448GIA-38 TS10ST-22
<br />Permit fF 384
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<br />TREAT�/�FA�I�►Sy � perllfy that
<br />have been authorized by the appllcable state agency to accept untreated medical wastes and that I have
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<br />receive6�R11.+�e6bf8�ISAiLII�.i wastes I
<br />accordance with the requuemenl outlined In that authorization.
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<br />PrintRype NaIF�LL�R
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<br />MAR 29 202 r
<br />sfer7'ed corttalners, � ou ft to : uha Ci , C
<br />Fresno, CA
<br />0
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<br />starred _____ corhainers, cu ft to : N. Salt Lake, t1T Dr Fresno, CA
<br />❑ Tr
<br />skrrcd ctxttelners cu R to : Braoks OR or
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