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MEDICAL WASTE TRACKING FORM NUMBER
<br />ip Stencycle' IN CASE OFME@GEfiCY COj�T-(1Cry REMTREC 1-800-424.930D eMDRCN�RHI7� t0-oeSTD
<br />0ll a LI,. f7 CUSTOMER NO, 21132
<br />ORIGISVn41.
<br />1. Generator's Name, Address and Telephone NumberATTKI: t IfIIl1 1111 1 1
<br />1 1 1 11 11 1 11 1 1
<br />Vanessa
<br />�II
<br />&rt
<br />EMERALD+TATTOO PIERCING iI�Ii��Ill�fll�� iIIIIIIIIiltil
<br />liI�IIII� NIiI
<br />2525 S HUTCHINS ST
<br />10/9/2020
<br />LODI, CA 95240-7146 (209) 578-'1580
<br />r
<br />6118197-002
<br />CUSTOMER NUMPER GENENATOn'S REOISTRATIONM
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C, NO.OF
<br />20, VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB14-(T) / TP14-(�) 44 Gal Tub (5.9 Cut ft)
<br />CONTAINERS:
<br />62, PGII
<br />cu FI.
<br />UN3291.
<br />Regulated Medical Waste, mos.,
<br />TB21-(_) / TP15-(�) / TY15-(�) 20 Gat Tub (2.7)
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291
<br />Regulated Medical Waste, n.o.s.,
<br />TB49-(_) / TP49-(�) / TY49-(�) 37 Gal Tub (4.9)6,21
<br />O
<br />PGII
<br />cu Ft.
<br />623 6111 Regulated Medical Waste, n.o.s.,
<br />T836 " 20 Gal Tub (Bin) (3.5 Cul ft)
<br />s Cu
<br />J Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.a.s„
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291,
<br />Regulated Medical Waste, n.os.,
<br />621 PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o,s.,
<br />WB43-(_) / PW43-(,�) / CW43-(�) 43 Gal Tub (5.7 cu
<br />)
<br />6.21 PGII
<br />Cu Ft.
<br />UN32911 Regulated Medical Waste, n.o.s.,
<br />FCR_, - BI05ystems Cardboard Box (4.2 CLI ft)
<br />6.21 PGII
<br />Cu FL
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certification: at hereby declare that the contents of this consignment are fully and accurate lyy TOTALS ►
<br />2
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<br />described above by the propershipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In all respects in proper condi Ion for transportaccording.to applicable International and national govern ental regulations."
<br />L
<br />L
<br />l�
<br />Y
<br />Printed 1,ped Name Signature
<br />Dale
<br />4. TRANSPOMER J ADKqI&
<br />Stericycle, Inc. This is a Through Shipment
<br />Phone g: �-
<br />11875 White Rock Rd
<br />Applicable Permit Numbers:
<br />3400
<br />2N
<br />Rancho ordova, A 55742
<br />cc �
<br />TRANSPORTER TIFICA I : Receipt el medical waste es described v .
<br />m
<br />PrinVrype Nmno ! Slgnalure
<br />Datejnq
<br />5. INTERM15OIA711 HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />Phone 6:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Flecolpl of medical waste as described above.
<br />Printrrype Name Signature
<br />Date
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADORESS:
<br />Phone H:
<br />W
<br />Applicable Permit Numbers:
<br />S
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt or medical waste as described above.
<br />Printrrype Name Signature
<br />Dale
<br />7, DISCREPANCY INDICATION
<br />A.Daalgnstad Facility: 86, Alternate Facility! BC, Alternate Facility:
<br />rjWF
<br />C3 aD. Alternate Facility:
<br />Steficycle, Inc. (Autoclave) Stericycle, Inc. (incinerator) Stedoycle, Inc. (Autoclave)
<br />Covanta Marion, Inc
<br />U
<br />1012 Starr Dr. 80 N. Foxboro Drive 4109 W. SvvlttAve
<br />9850 f3mvhlaha Road NE
<br />LL
<br />Yuba Cihi, CA 95993 North Sak Lake. UT 84054 F�[e5�n�o, CA 93722
<br />DVtrDc.71
<br />Brooks, OR 97305
<br />F
<br />(fi39)766-969b (91)1)926-1171 kpjt
<br />(596)398.9999
<br />Z
<br />TSIOST-89 3A-448/JA-36 TSfOST-22
<br />Permit#304
<br />OCT 13 2020
<br />Lu
<br />TREATMENTI thaf I have been state agency accept untreated medical wastes and that I have
<br />Imo- a
<br />ned,l4 (hRtr34thto
<br />requiremethe nllleutile
<br />the aboveLITY:
<br />received Indicated wlastes In accordance With lhe
<br />7 rizallon.
<br />Prinurrype Name 3e 0 Slgnalure
<br />Date
<br />TdR5 eiTe COD aIRGFS, CLI O ' UOa UI Y, C O Ye5n0.
<br />❑ Transferred Containers, Lii It to ; hi. Salt a a, LIT or Fresno, C4
<br />J
<br />❑ Transferred containers, cu ft tt1 : 8ruoks, OR or
<br />_
<br />ORIGISVn41.
<br />
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