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MEDICAL WASTE TRACKING FORM NUMBER
<br />e Steric clee IN CASE OF EMERGENCY CONTACTy'CHEMTREC I-e0D-424.9300
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<br />STANDARD MANIFEST 001-10•oe•STO
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<br />Route #: 033 ,- 11 CUSTOMER NO, 21132
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<br />1. Generator's Name, Address and Telephone Number
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<br />EMEOtt
<br />RALDS TATTOO &~PIERCING
<br />2525 S HUTCHINS ST
<br />12122/2020
<br />LORI, CA 95240-7146 (209) 578-1560
<br />1 1 61 97-0 02
<br />CD$TOMEq NIfM6Ee GmEAATaq'S Rmurr Arccu;
<br />2A, DESCRIPTION OF WASTE
<br />29- CONTAINER TYPE
<br />2C, NO, OF
<br />2D, VOLUME
<br />Regulated Medical Waste, 11.63.,
<br />7614-(_) ! TP14-(__ 44 Gal Tub (5.0 CLI ft)
<br />CONTAINERS
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<br />11113291, Regulated Medical Waste, n.o.s,,T621_(�j
<br />/ TP15-(_._ / TY'15-(�) 20 Gal Tub (2,7)
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<br />UN3291 Regulated Medical Waste, n.o,s.,TE49-(_)
<br />/ TP4fl-(.,_) / TY49-(_-�) 37 Cal Tub (4.'3)
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<br />6.2, PGII
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<br />UN3291
<br />Regulated Medical Waste, n.o,s.,
<br />B 5 26 Cal Tub (BID) (3.5 cu ft)
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<br />UN3291
<br />Regulated Medical Waste,
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<br />UN3291, Regulated Medical Waste, 11.63.,
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<br />s23PG,I Regulated Medical Waste, n.o.s„
<br />WB43-(�)/ FWA3-() / CW43-(-______-) 43 Gal Tub (5.7 cu
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<br />UN3291, Regulated Medical Waste, mos.,
<br />KR_- Siosysterr;s Cardboard Boy (4.2 cu ft)
<br />6.21 PGII
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<br />UN3291 Regulated Medical Waste, n.a,s„
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<br />3. Generator's Certification: 01 hereby declare that the contents of this consignment are fully and accurately TOTALS ►
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<br />described above by the proper shipping name, and are classil'a kaged, marked and labelled/placarded, and
<br />are in all respects in proper( condition for tmnsporf according to ppii ble Internallonal and national gcver e I regulations:'
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<br />Printed/Typed Name v r
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<br />4. TRANSPORTER 1 ADDRESS: VPhone
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<br />Stel7Cycle, Inc, Q This is a Through Shipment
<br />Applicable Permit Numbers:
<br />11875 White Rock Rd
<br />3400
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<br />Rancho Cordo%la, A 95742
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<br />cribe v .
<br />TRANSPORTER RTIFICATI : Receipt of medical waste as desEA
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<br />PrrnVTypa Name Signature
<br />Dem
<br />5. INTERMEDIAf E HANDLER 2/T ANSPORTER 2 ADDRESS:
<br />Phone M:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER (TRANSPORTER CERTIFICATION: Receipt or medical waste as described above.
<br />PrinttType Name Signature
<br />Date
<br />64 INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS:
<br />Phone N:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
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<br />Print/Type Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION '
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<br />Designated Facility; 8e, Alternate Facility: 8C, Alternate Faclllty:
<br />E] So. Alternate Facility:
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<br />Sterlcycle, Inc. (Autoclave) Stericycle, Inc. (Incinerator) Stericycle, trio. (AUtoClava)
<br />Covanta Marion, Inc
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<br />1612 Starr Dr. 96 Al. Foxboro Drive 4135 W. S ft Ave
<br />4858 6r oklahe Road NE
<br />Yuba City, CA 95993 North Salt Lake. UT 84954 Fresncq,S1,$A
<br />Brooks, OR 97305
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<br />(538)755-0585 (801)936-1171 (866)784E�
<br />(595)39 0860
<br />4 $-
<br />TS/OST-80 3A-448/JA 36 TSIOSW2 9 2020
<br />Permit 0 364
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the above Indicated wastes in accordance with the requirement outlined in that 4hiakyVit.
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<br />Print/rypo Name Signature
<br />Date
<br />containers, Cu ft to : L1bg City, CA
<br />o Fresno, CA
<br />TT--TTE40ofransferieed
<br />IJ Transferred containers, cu If to: N. Salt Lake, LIT or Fresno, CA
<br />❑ TransfelT�d containers, Cu ft to : 61v0ks, OR or
<br />ORIGINAL
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