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sj0s� <br /> Medical Waste Tracking Form <br /> St3LLJTlONS <br /> 1.Generator's Name,Address and Phone Number <br /> •(^-0 <br /> • i31-} 63 taNWy <br /> . LoGk �--on, gS� 3� <br /> Customer Number Generator's Registration# <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE/WASTE STREAM 2C. NO.OF 2D. VOLUME <br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS <br /> 6.2,PGII m <br /> Z <br /> UN3291,Regulated Medical Waste,n.o.s., m <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII j <br /> UN3291,Regulated Medical Waste,n.o.s.,I A <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2.PGII j <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> UN3291,Regulated Medical Waste,n.o.s., <br /> 6.2,PGII <br /> 3. Generators certification:°I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aii ,S <br /> are classed,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national <br /> government regulations,(" $/_'�l/` (1 Z <br /> XPnnted/fypedrd . �`� vs�' " Signatu Date 21— 2-7 <br /> -4:TRANSPORTER-ADDRES: PHONE# t"t' <br /> 23575 Cabot Blvd Ste 203,Hayward,CA,94545 APO-We PertndNanbas: Z� <br /> Sri rA <br /> CO <br /> -rtea <br /> TRANSPORTATION CERTIFICATION:Recaivtormerscafwaste asdesceoedatrnre 0y <br /> Pdnted/TypedName (�.. Signature \\ Date A <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: PHONE'# <br /> Ap�kabmPeaNt Numbers: 2 <br /> �mz <br /> N <br /> 090 <br /> INTERMEDIATE HANDLER/TRANSPORTATION CERTIFICATION:rte�ptotmedicalwasmasdasamdaeore m D i <br /> ADm <br /> �p <br /> Printed/Typed Name Signaturem N <br /> Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: <br /> PHONE# Z p <br /> {D <br /> Apq'rc,2We Pmrtifl Numbers y m m <br /> A <br /> 090 <br /> A <br /> INTERMEDIATE HANDLER/TRANSPORTATIONCERTIFICATION:Reoeptofaadcalwasteasdescbedabu p A <br /> Ma <br /> L Discrepancy Indication: <br /> Waste Stream Solutions ® Stericycle ❑ Stericycle ® D <br /> 683 New York Dr.,Pomona CA 91768 2775 E.26th St.,Vernon CA 90023 80 N.1100 W.N.Salt Lake UT 84054 � <br /> 800-550-0559 Permit TS/OST-84 323-362-3009 Permit TS/OST-26 801-835-1555 Permit 91-02 Z <br /> 71 <br /> 0 <br /> Treatment Facility:I certify that I have been authorized by the applicable state of California to accept untreated medical waste and that I have received the above indicated wastes in accordance with the <br /> requirement outlined in that authorization. <br /> Printed/Typed Name Signature Date <br /> White-Generator Canary-Transporter Pink-Treatment Facility Golden Rod-Generator <br />